Provider Demographics
NPI:1033115878
Name:BRODERICK, CARLA MARIE (APRN)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:MARIE
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:CARLA
Other - Middle Name:M
Other - Last Name:HOLDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 950244
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0244
Mailing Address - Country:US
Mailing Address - Phone:502-953-4700
Mailing Address - Fax:502-776-8912
Practice Address - Street 1:2215 PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40212
Practice Address - Country:US
Practice Address - Phone:502-774-8631
Practice Address - Fax:502-996-8309
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2023-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3002744363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000200893OtherANTHEM
KY78009859Medicaid
KY000000200893OtherANTHEM
KYS70310Medicare UPIN
KY0838611Medicare PIN