Healthcare Provider Details

I. General information

NPI: 1891356606
Provider Name (Legal Business Name): NICOLE BRODEN OD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2019
Last Update Date: 09/07/2021
Certification Date: 09/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

478 BURNSIDE AVE
EAST HARTFORD CT
06108-2425
US

IV. Provider business mailing address

478 BURNSIDE AVE
EAST HARTFORD CT
06108-2425
US

V. Phone/Fax

Practice location:
  • Phone: 860-528-1359
  • Fax:
Mailing address:
  • Phone: 860-528-1359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number003131
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: