Healthcare Provider Details

I. General information

NPI: 1104568831
Provider Name (Legal Business Name): MARY KATE BRODESSER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2022
Last Update Date: 04/12/2022
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2141 PALOMAR AIRPORT RD STE 350
CARLSBAD CA
92011-1451
US

IV. Provider business mailing address

831 E 3RD AVE UNIT 13
ESCONDIDO CA
92025-4500
US

V. Phone/Fax

Practice location:
  • Phone: 760-438-0078
  • Fax:
Mailing address:
  • Phone: 760-533-8602
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247000000X
TaxonomyHealth Information Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: