Provider Demographics
NPI:1427399690
Name:BRODERICK, MELVA JUNE (RN)
Entity Type:Individual
Prefix:
First Name:MELVA
Middle Name:JUNE
Last Name:BRODERICK
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 1:6881 W STATE ST
Mailing Address - Street 2:#8
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83714-7428
Mailing Address - Country:US
Mailing Address - Phone:208-850-2653
Mailing Address - Fax:
Practice Address - Street 1:6881 W STATE ST
Practice Address - Street 2:#8
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83714-7428
Practice Address - Country:US
Practice Address - Phone:208-850-2653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-12
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN-33864163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse