Provider Demographics
NPI:1184190647
Name:BROSKE, MELISSA RENEE (FNP)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:RENEE
Last Name:BROSKE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:RENEE
Other - Last Name:THAKORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1116 BLACKFOOT DR
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-5470
Mailing Address - Country:US
Mailing Address - Phone:706-294-6485
Mailing Address - Fax:
Practice Address - Street 1:1301 BROAD ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-1055
Practice Address - Country:US
Practice Address - Phone:706-922-5864
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-22
Last Update Date:2018-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN217143363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily