Provider Demographics
NPI:1114774809
Name:KACZCOUGHNETT, BROOKE JAYME (NP)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:JAYME
Last Name:KACZCOUGHNETT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:BROOKE
Other - Middle Name:JAYME
Other - Last Name:VANCOUGHNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:14 RAVENSWOOD TER
Mailing Address - Street 2:
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14225-1145
Mailing Address - Country:US
Mailing Address - Phone:315-783-3115
Mailing Address - Fax:
Practice Address - Street 1:14 RAVENSWOOD TER
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14225-1145
Practice Address - Country:US
Practice Address - Phone:315-783-3115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-01
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY311716363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health