Provider Demographics
NPI:1710247556
Name:BROKKE, AMANDA JANE (CRNA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JANE
Last Name:BROKKE
Suffix:
Gender:F
Credentials:CRNA
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 208379
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-8382
Mailing Address - Country:US
Mailing Address - Phone:512-485-7208
Mailing Address - Fax:844-364-8678
Practice Address - Street 1:2701 E STAN SCHLUETER LOOP STE 100
Practice Address - Street 2:
Practice Address - City:KILLEEN
Practice Address - State:TX
Practice Address - Zip Code:76542-3810
Practice Address - Country:US
Practice Address - Phone:855-876-7246
Practice Address - Fax:855-277-5070
Is Sole Proprietor?:No
Enumeration Date:2012-05-28
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX88406367500000X
TXAP121982367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP121982OtherTEXAS CRNA LICENSE
TX2J7040OtherTEXAS MEDICARE PTAN