Provider Demographics
NPI:1932157484
Name:BROOME, KENDALL MARK (CRNA)
Entity Type:Individual
Prefix:MR
First Name:KENDALL
Middle Name:MARK
Last Name:BROOME
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:
Other - Last Name:BROOME
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 740209
Mailing Address - Street 2:DEPT 1041
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-0209
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5671 PEACHTREE-DUNWOODY RD
Practice Address - Street 2:STE 680
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-5014
Practice Address - Country:US
Practice Address - Phone:404-705-6985
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2021-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN 135213367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered