Provider Demographics
NPI:1174277677
Name:WILCZAK, BROOKE ELAINE (CRNA)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:ELAINE
Last Name:WILCZAK
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1077 DUVAL ST APT 103
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40515-6482
Mailing Address - Country:US
Mailing Address - Phone:703-314-1780
Mailing Address - Fax:
Practice Address - Street 1:800 ROSE ST
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-6482
Practice Address - Country:US
Practice Address - Phone:859-323-5956
Practice Address - Fax:859-323-1080
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-04
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY3018265367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL0OtherDO NOT HAVE SUCH NUMBERS