Healthcare Provider Details

I. General information

NPI: 1114691797
Provider Name (Legal Business Name): MARY KAY BRODRICK RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2021
Last Update Date: 08/05/2021
Certification Date: 08/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48190 W 10 MILE RD
NOVI MI
48374-2813
US

IV. Provider business mailing address

48190 W 10 MILE RD
NOVI MI
48374-2813
US

V. Phone/Fax

Practice location:
  • Phone: 313-590-5835
  • Fax: 708-910-3138
Mailing address:
  • Phone: 313-590-5835
  • Fax: 708-910-3138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number4704238653
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: