Provider Demographics
NPI:1306229349
Name:GACKENBACH, BRIAN KEITH (APRN)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:KEITH
Last Name:GACKENBACH
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-588-0328
Mailing Address - Fax:
Practice Address - Street 1:530 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1675
Practice Address - Country:US
Practice Address - Phone:502-217-1053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-08
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3009514363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care