Provider Demographics
NPI:1730796079
Name:KMIECIK, BROOK
Entity type:Individual
Prefix:MS
First Name:BROOK
Middle Name:
Last Name:KMIECIK
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 1:3857 LITTLE TROUT RD
Mailing Address - Street 2:
Mailing Address - City:LAC DU FLAMBEAU
Mailing Address - State:WI
Mailing Address - Zip Code:54538-9313
Mailing Address - Country:US
Mailing Address - Phone:715-661-3641
Mailing Address - Fax:
Practice Address - Street 1:9198A THRALL RD
Practice Address - Street 2:
Practice Address - City:WOODRUFF
Practice Address - State:WI
Practice Address - Zip Code:54568-9329
Practice Address - Country:US
Practice Address - Phone:715-439-4377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program