Provider Demographics
NPI:1194507954
Name:MACTAGGART, BROOKE ANN (CPNP-PC)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:ANN
Last Name:MACTAGGART
Suffix:
Gender:F
Credentials:CPNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:715 ANDERSON ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:IA
Mailing Address - Zip Code:52057-1401
Mailing Address - Country:US
Mailing Address - Phone:319-480-2540
Mailing Address - Fax:
Practice Address - Street 1:105 E BUTLER ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:IA
Practice Address - Zip Code:52057-1606
Practice Address - Country:US
Practice Address - Phone:563-927-9400
Practice Address - Fax:563-927-6224
Is Sole Proprietor?:No
Enumeration Date:2023-10-17
Last Update Date:2024-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAC176768363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics