MEDICARE: MRS. MARY ANN BRODA C.P.N.P.

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	363LP0200X	Pediatric Nurse Practitioner	4704119440	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	470411940	OTHER	MI	LICENSE
2	83 20029	OTHER	MI	PHP

General Provider Information

NPI Number	:	1356442842
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARY ANN BRODA C.P.N.P.

Provider Business Mailing Address
First Line	:	106 E MAIN ST
Second Line	:
City	:	SPRING ARBOR
State	:	MI
Zip	:	49283-9701
Country	:	US
Telephone Number	:	517-740-9869
Fax Number	:	517-750-6625

Provider Business Practice Location Address
First Line	:	106 E MAIN ST
Second Line	:
City	:	SPRING ARBOR
State	:	MI
Zip	:	49283-9701
Country	:	US
Telephone Number	:	517-750-6352
Fax Number	:	517-750-6625

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

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	02/16/2016

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Directions to “ MRS. MARY ANN BRODA C.P.N.P.” Practice Location

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