Provider Demographics
NPI:1467695684
Name:BROEDEL, JENNIFER MARIE (RN)
Entity Type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:MARIE
Last Name:BROEDEL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:JENNIFER
Other - Middle Name:MARIE
Other - Last Name:MANNONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:8417A REMAGEN ST
Mailing Address - Street 2:
Mailing Address - City:FORT IRWIN
Mailing Address - State:CA
Mailing Address - Zip Code:92310-2437
Mailing Address - Country:US
Mailing Address - Phone:760-380-5434
Mailing Address - Fax:
Practice Address - Street 1:8417A REMAGEN ST
Practice Address - Street 2:
Practice Address - City:FORT IRWIN
Practice Address - State:CA
Practice Address - Zip Code:92310-2437
Practice Address - Country:US
Practice Address - Phone:760-380-5434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-17
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR174279163W00000X
CA724630163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163W00000XNursing Service ProvidersRegistered Nurse