Provider Demographics
NPI:1487194015
Name:BROASTER, KERRA
Entity Type:Individual
Prefix:
First Name:KERRA
Middle Name:
Last Name:BROASTER
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 1:604 SAINT NICHOLAS AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10030-1492
Mailing Address - Country:US
Mailing Address - Phone:347-213-6443
Mailing Address - Fax:
Practice Address - Street 1:604 SAINT NICHOLAS AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10030-1492
Practice Address - Country:US
Practice Address - Phone:347-213-6443
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-01
Last Update Date:2019-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY779691163W00000X
NY323633164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse