Provider Demographics
NPI:1003434283
Name:BRODEN, LUISA
Entity Type:Individual
Prefix:
First Name:LUISA
Middle Name:
Last Name:BRODEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 E 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:99114-9463
Mailing Address - Country:US
Mailing Address - Phone:509-675-3813
Mailing Address - Fax:
Practice Address - Street 1:902 N ALMON ST APT 3
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-8544
Practice Address - Country:US
Practice Address - Phone:509-675-3813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-14
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAUDWW750166632OtherREGENCE