Provider Demographics
NPI:1033385406
Name:DESEREE BRODDIE
Entity Type:Organization
Organization Name:DESEREE BRODDIE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LPN
Authorized Official - Prefix:MRS
Authorized Official - First Name:DESEREE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:BRODDIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-726-8253
Mailing Address - Street 1:128 STUBBS LN
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:39817-1937
Mailing Address - Country:US
Mailing Address - Phone:229-726-8253
Mailing Address - Fax:
Practice Address - Street 1:128 STUBBS LN
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:39817-1937
Practice Address - Country:US
Practice Address - Phone:229-726-8253
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN059350251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care