Provider Demographics
NPI:1790039196
Name:BROKAMP, KELSEY RENEE (ANP-BC)
Entity Type:Individual
Prefix:MRS
First Name:KELSEY
Middle Name:RENEE
Last Name:BROKAMP
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21051 ROAD T
Mailing Address - Street 2:
Mailing Address - City:FORT JENNINGS
Mailing Address - State:OH
Mailing Address - Zip Code:45844-9307
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:140 FOX RD
Practice Address - Street 2:
Practice Address - City:VAN WERT
Practice Address - State:OH
Practice Address - Zip Code:45891-2475
Practice Address - Country:US
Practice Address - Phone:419-238-7727
Practice Address - Fax:419-238-7768
Is Sole Proprietor?:No
Enumeration Date:2012-11-07
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP13989363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0080308Medicaid