Provider Demographics
NPI:1386981108
Name:BROACH, MICHELLE K (CRNA)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:K
Last Name:BROACH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:A
Other - Last Name:KALEJTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 551420
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33355-1420
Mailing Address - Country:US
Mailing Address - Phone:800-243-3839
Mailing Address - Fax:855-851-4405
Practice Address - Street 1:777 HEMLOCK ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2102
Practice Address - Country:US
Practice Address - Phone:866-507-5244
Practice Address - Fax:855-851-4405
Is Sole Proprietor?:No
Enumeration Date:2013-01-14
Last Update Date:2014-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN175404367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered