MEDICARE: MANDY IRENE BRODERICK

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	1710I1002X	Independent Duty Corpsman

General Provider Information

NPI Number	:	1497018014
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MANDY IRENE BRODERICK

Provider Business Mailing Address
First Line	:	USS JASON DUNHAM DDG 109
Second Line	:
City	:	FPO
State	:	AE
Zip	:	09567-1303
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	USS JASON DUNHAM DDG 109
Second Line	:
City	:	FPO
State	:	AE
Zip	:	09567-1303
Country	:	US
Telephone Number	:	757-445-6115
Fax Number	:

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

Provider Enumeration Date	:	06/19/2012
Last Update Date	:	06/19/2012

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