Provider Demographics
NPI:1467449975
Name:BROAD, MICHELE RACHEAL (NP)
Entity Type:Individual
Prefix:MRS
First Name:MICHELE
Middle Name:RACHEAL
Last Name:BROAD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:CATHY
Other - Middle Name:LEE
Other - Last Name:SHAFFER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LVN
Mailing Address - Street 1:4397 WILLOWCREEK CT
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92545-9065
Mailing Address - Country:US
Mailing Address - Phone:951-766-0357
Mailing Address - Fax:951-304-2735
Practice Address - Street 1:41529 IVY ST
Practice Address - Street 2:200-A
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-9457
Practice Address - Country:US
Practice Address - Phone:951-304-3180
Practice Address - Fax:951-304-2735
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA428809363LA2200X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Not Answered363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health