Provider Demographics
NPI:1386924751
Name:BROUK, KASSECH (LPN)
Entity type:Individual
Prefix:
First Name:KASSECH
Middle Name:
Last Name:BROUK
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 1:9 CHARTER OAKS DRIVE
Mailing Address - Street 2:
Mailing Address - City:PITTSFORD
Mailing Address - State:NY
Mailing Address - Zip Code:14534
Mailing Address - Country:US
Mailing Address - Phone:585-953-7833
Mailing Address - Fax:
Practice Address - Street 1:150 STATE ST
Practice Address - Street 2:SUITE 140
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14614-1353
Practice Address - Country:US
Practice Address - Phone:585-454-3550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-17
Last Update Date:2011-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY195906-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse