Healthcare Provider Details

I. General information

NPI: 1194714576
Provider Name (Legal Business Name): LAURA BRODHAG
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2005
Last Update Date: 07/13/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PSC 103 BOX 3615
APO AE
09603
US

IV. Provider business mailing address

PSC 103 BOX 3615
APO AE
09603
US

V. Phone/Fax

Practice location:
  • Phone: 011390434305247
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number31179
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: