Provider Demographics
NPI:1114691797
Name:BRODRICK, MARY KAY (RN)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:KAY
Last Name:BRODRICK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48190 W 10 MILE RD
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48374-2813
Mailing Address - Country:US
Mailing Address - Phone:313-590-5835
Mailing Address - Fax:708-910-3138
Practice Address - Street 1:48190 W 10 MILE RD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48374-2813
Practice Address - Country:US
Practice Address - Phone:313-590-5835
Practice Address - Fax:708-910-3138
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-05
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704238653163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4704238653OtherNURSING LICENSE