Healthcare Provider Details

I. General information

NPI: 1629444823
Provider Name (Legal Business Name): STEPHANIE LAUREN BRODERICK CNM, WHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE LAUREN WAGGONER

II. Dates (important events)

Enumeration Date: 08/11/2015
Last Update Date: 05/10/2022
Certification Date: 05/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 INDIAN AVE
AURORA IL
60505-3137
US

IV. Provider business mailing address

400 N HIGHLAND AVE
AURORA IL
60506-3814
US

V. Phone/Fax

Practice location:
  • Phone: 630-892-4355
  • Fax:
Mailing address:
  • Phone: 630-892-4355
  • Fax: 630-892-0262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number209013055
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: