Provider Demographics
NPI:1902348493
Name:KENNARD, BROOKE (APN)
Entity Type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:KENNARD
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 BROAD CREEK RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61704-8525
Mailing Address - Country:US
Mailing Address - Phone:309-532-1748
Mailing Address - Fax:
Practice Address - Street 1:326 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-3462
Practice Address - Country:US
Practice Address - Phone:309-451-9595
Practice Address - Fax:309-451-9583
Is Sole Proprietor?:No
Enumeration Date:2016-11-15
Last Update Date:2023-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71008773A363LF0000X
IL209-014496363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily