Healthcare Provider Details

I. General information

NPI: 1932473741
Provider Name (Legal Business Name): NICOLE BRODERSON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/27/2012
Last Update Date: 07/31/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 LUISA ST SUITE N
SANTA FE NM
87505-4073
US

IV. Provider business mailing address

1421 LUISA ST SUITE N
SANTA FE NM
87505-4073
US

V. Phone/Fax

Practice location:
  • Phone: 505-428-0072
  • Fax: 888-256-1158
Mailing address:
  • Phone: 505-428-0072
  • Fax: 888-256-1158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMB2485490
License Number StateNM

VIII. Authorized Official

Name: MISS NICOLE R BRODERSON
Title or Position: NURSE PRACTITIONER
Credential: CNP
Phone: 505-428-0072