Provider Demographics
NPI:1396120671
Name:BROKAW, AMY JO (LPN)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:JO
Last Name:BROKAW
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 KENNEDY DR
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:OH
Mailing Address - Zip Code:43724-9004
Mailing Address - Country:US
Mailing Address - Phone:740-732-5211
Mailing Address - Fax:740-732-4175
Practice Address - Street 1:43 KENNEDY DR
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:OH
Practice Address - Zip Code:43724-9004
Practice Address - Country:US
Practice Address - Phone:740-732-5211
Practice Address - Fax:740-732-4175
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-28
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH119768-MEDS164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0136187Medicaid
OH0136187Medicaid