Healthcare Provider Details

I. General information

NPI: 1124308689
Provider Name (Legal Business Name): NICOLE BRODERSON RN, MSN, PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2011
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

PO BOX 23901
SANTA FE NM
87502-3901
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 Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberCNP-01815
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: