Provider Demographics
NPI:1215386297
Name:BROCKMAN, KRISTI
Entity Type:Individual
Prefix:
First Name:KRISTI
Middle Name:
Last Name:BROCKMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5203 S 65TH PL
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-4184
Mailing Address - Country:US
Mailing Address - Phone:479-866-0016
Mailing Address - Fax:
Practice Address - Street 1:670 W FIREWEED LN STE 160
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99503-2561
Practice Address - Country:US
Practice Address - Phone:907-770-0862
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-09
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK110602164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse