MEDICARE: MS. GAYLE A BRODBECK R.N.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program	RN 508158	AZ

General Provider Information

NPI Number	:	1245461615
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. GAYLE A BRODBECK R.N.

Provider Business Mailing Address
First Line	:	PO BOX 5070
Second Line	:
City	:	MOHAVE VALLEY
State	:	AZ
Zip	:	86446-5070
Country	:	US
Telephone Number	:	928-768-4538
Fax Number	:

Provider Business Practice Location Address
First Line	:	1419 E. WILLOW DR.
Second Line	:
City	:	MOHAVE VALLEY
State	:	AZ
Zip	:	86440
Country	:	US
Telephone Number	:	928-768-4538
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/04/2009
Last Update Date	:	08/04/2009

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