Provider Demographics
NPI:1215183363
Name:BRODERICK, SHAWNE S (CNM)
Entity Type:Individual
Prefix:
First Name:SHAWNE
Middle Name:S
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 WASHINGTON PL
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03110-6736
Mailing Address - Country:US
Mailing Address - Phone:603-695-2900
Mailing Address - Fax:
Practice Address - Street 1:5 WASHINGTON PL
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:NH
Practice Address - Zip Code:03110-6736
Practice Address - Country:US
Practice Address - Phone:603-695-2900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-08
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA239794367A00000X
NH051632-23367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH000806602Medicare PIN
NH000806602Medicare PIN