MEDICARE: MELISSA BRODER FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	R211680	MD

General Provider Information

NPI Number	:	1871071100
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELISSA BRODER FNP-C

Provider Business Mailing Address
First Line	:	1121 UNIVERSITY BLVD W APT 815
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20902-3320
Country	:	US
Telephone Number	:	410-804-4250
Fax Number	:

Provider Business Practice Location Address
First Line	:	10801 LOCKWOOD DR STE 300
Second Line	:
City	:	SILVER SPRING
State	:	MD
Zip	:	20901-1562
Country	:	US
Telephone Number	:	301-681-0004
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/30/2018
Last Update Date	:	07/30/2018

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