Healthcare Provider Details

I. General information

NPI: 1285944223
Provider Name (Legal Business Name): MONICA BROADIE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/08/2010
Last Update Date: 10/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2133 W LEXINGTON ST
CHICAGO IL
60612-3707
US

IV. Provider business mailing address

2133 W LEXINGTON ST
CHICAGO IL
60612-3707
US

V. Phone/Fax

Practice location:
  • Phone: 312-746-4664
  • Fax: 312-746-6526
Mailing address:
  • Phone: 312-746-4664
  • Fax: 312-746-6526

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number0413000441
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: