Provider Demographics
NPI:1265044861
Name:BROCKWAY, KELLI ELIZABETH
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:ELIZABETH
Last Name:BROCKWAY
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 1:130 CASTLE LN
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:IA
Mailing Address - Zip Code:50622-1033
Mailing Address - Country:US
Mailing Address - Phone:319-984-5311
Mailing Address - Fax:
Practice Address - Street 1:2501 HUDSON RD
Practice Address - Street 2:
Practice Address - City:CEDAR FALLS
Practice Address - State:IA
Practice Address - Zip Code:50614-0014
Practice Address - Country:US
Practice Address - Phone:319-273-7401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer