Healthcare Provider Details

I. General information

NPI: 1174879282
Provider Name (Legal Business Name): KIERON JAMES BRODERICK RN, ACNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/25/2012
Last Update Date: 02/18/2022
Certification Date: 02/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1208 E CROSS ST
CENTERVILLE IA
52544-3501
US

IV. Provider business mailing address

3901 SPICEWOOD SPRINGS RD STE 201
AUSTIN TX
78759-8723
US

V. Phone/Fax

Practice location:
  • Phone: 816-477-7200
  • Fax:
Mailing address:
  • Phone: 877-279-5960
  • Fax: 877-384-3106

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberL166512
License Number StateIA
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number2012024476
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: