Provider Demographics
NPI:1669719845
Name:BROMAGEN, MARY CAROLINE (ACNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:CAROLINE
Last Name:BROMAGEN
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:740 S LIMESTONE
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-0284
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:310 S LIMESTONE
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40508-3008
Practice Address - Country:US
Practice Address - Phone:859-226-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-09
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007780363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care