Provider Demographics
NPI:1427730738
Name:GRANGE, BROOKLYN MCNEIL
Entity type:Individual
Prefix:
First Name:BROOKLYN
Middle Name:MCNEIL
Last Name:GRANGE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8921 W HACKAMORE DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83709-1673
Mailing Address - Country:US
Mailing Address - Phone:208-994-4123
Mailing Address - Fax:800-431-6309
Practice Address - Street 1:8921 W HACKAMORE DR
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83709-1673
Practice Address - Country:US
Practice Address - Phone:208-994-4123
Practice Address - Fax:800-431-6309
Is Sole Proprietor?:No
Enumeration Date:2023-08-04
Last Update Date:2025-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID1427730738363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant