Healthcare Provider Details

I. General information

NPI: 1154707784
Provider Name (Legal Business Name): MS. ALLIE BRODHEAD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2015
Last Update Date: 04/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2288 AUBURN BLVD SUITE 200
SACRAMENTO CA
95821-1618
US

IV. Provider business mailing address

1528 EUREKA RD STE 103
ROSEVILLE CA
95661-3047
US

V. Phone/Fax

Practice location:
  • Phone: 916-564-3377
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95001842
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: