Provider Demographics
NPI:1467433243
Name:BRODRICK, ELLEN M (CNM)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:M
Last Name:BRODRICK
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 1:777 BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80204-4597
Mailing Address - Country:US
Mailing Address - Phone:303-602-9135
Mailing Address - Fax:
Practice Address - Street 1:777 BANNOCK ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-4507
Practice Address - Country:US
Practice Address - Phone:303-602-9135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI138047163W00000X, 367A00000X
WI2179363L00000X
MNR 207187-5367A00000X
MN32367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
P74679Medicare UPIN
MN420001197Medicare PIN