Basic Information
| Provider Information | |||||||||
| NPI: | 1043620669 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROSIUS | ||||||||
| FirstName: | KLA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 785 5TH AVE STE 3 | ||||||||
| Address2: | |||||||||
| City: | CHAMBERSBURG | ||||||||
| State: | PA | ||||||||
| PostalCode: | 172014232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7172639555 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6155 ANTHONY HWY | ||||||||
| Address2: | |||||||||
| City: | WAYNESBORO | ||||||||
| State: | PA | ||||||||
| PostalCode: | 172689718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177493181 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2014 | ||||||||
| LastUpdateDate: | 03/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 363L00000X | RN703306 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | SP022125 | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | SP022125 | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 14672457 | 01 | PA | CAQH | OTHER | 103802749 | 05 | PA | MEDICAID | 1043620669 | 01 | NPI | OTHER |