Provider Demographics
NPI:1902427040
Name:FOGLE, BROOKLYNNE ELIZABETH (PA)
Entity Type:Individual
Prefix:MRS
First Name:BROOKLYNNE
Middle Name:ELIZABETH
Last Name:FOGLE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:BROOKLYNNE
Other - Middle Name:ELIZABETH
Other - Last Name:SIMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 843966
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64184-3966
Mailing Address - Country:US
Mailing Address - Phone:573-884-3300
Mailing Address - Fax:573-884-0943
Practice Address - Street 1:2707 W EDGEWOOD DR STE 102
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-5886
Practice Address - Country:US
Practice Address - Phone:573-761-1830
Practice Address - Fax:573-761-1829
Is Sole Proprietor?:No
Enumeration Date:2020-04-29
Last Update Date:2023-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021003259363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant