Provider Demographics
NPI:1568801975
Name:BROZAK, KIMBERLY ANN (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:ANN
Last Name:BROZAK
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:ANN
Other - Last Name:GIBSON-LAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:141 COLUMBUS ROAD
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:OH
Mailing Address - Zip Code:45701-1315
Mailing Address - Country:US
Mailing Address - Phone:740-592-4229
Mailing Address - Fax:740-592-4010
Practice Address - Street 1:141 COLUMBUS ROAD
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:OH
Practice Address - Zip Code:45701-1315
Practice Address - Country:US
Practice Address - Phone:740-592-4229
Practice Address - Fax:740-592-4010
Is Sole Proprietor?:No
Enumeration Date:2013-06-19
Last Update Date:2016-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.14576-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0086503Medicaid
OH0086503Medicaid