Healthcare Provider Details

I. General information

NPI: 1639254675
Provider Name (Legal Business Name): DONNA LEE BRODERICK C.P.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 09/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 HIGH ST
BELFAST ME
04915-6351
US

IV. Provider business mailing address

355 N RIDGE RD
MONTVILLE ME
04941-4504
US

V. Phone/Fax

Practice location:
  • Phone: 207-338-0708
  • Fax: 207-338-0708
Mailing address:
  • Phone: 207-342-3060
  • Fax: 207-342-3060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: