Provider Demographics
NPI:1477597680
Name:BROEKHOF, KELLY LYNNE (BSN)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:LYNNE
Last Name:BROEKHOF
Suffix:
Gender:F
Credentials:BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:644 ORISKANY ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32227-1712
Mailing Address - Country:US
Mailing Address - Phone:904-372-9141
Mailing Address - Fax:
Practice Address - Street 1:BLDG 2104 MASSEY AVE
Practice Address - Street 2:NAVAL STATION MAYPORT
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32222
Practice Address - Country:US
Practice Address - Phone:904-270-4293
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRN 45281163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management