Provider Demographics
NPI:1720227465
Name:BROCKWAY, KATHLEEN ELIZABETH
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:ELIZABETH
Last Name:BROCKWAY
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 1:13740 BEACH BLVD STE 404
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-6036
Mailing Address - Country:US
Mailing Address - Phone:904-223-5595
Mailing Address - Fax:904-223-5594
Practice Address - Street 1:13740 BEACH BLVD STE 404
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-6036
Practice Address - Country:US
Practice Address - Phone:904-223-5595
Practice Address - Fax:904-223-5594
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-19
Last Update Date:2009-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier