Provider Demographics
NPI:1356442842
Name:BRODA, MARY ANN (CPNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ANN
Last Name:BRODA
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRING ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:49283-9701
Mailing Address - Country:US
Mailing Address - Phone:517-740-9869
Mailing Address - Fax:517-750-6625
Practice Address - Street 1:106 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRING ARBOR
Practice Address - State:MI
Practice Address - Zip Code:49283-9701
Practice Address - Country:US
Practice Address - Phone:517-750-6352
Practice Address - Fax:517-750-6625
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2016-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704119440363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI470411940OtherLICENSE
MI83 20029OtherPHP