Provider Demographics
NPI:1598316986
Name:WRIGHT-BRODERICK, RONDA
Entity Type:Individual
Prefix:
First Name:RONDA
Middle Name:
Last Name:WRIGHT-BRODERICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3724 COOK AVE APT B
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63113-3837
Mailing Address - Country:US
Mailing Address - Phone:314-299-5147
Mailing Address - Fax:
Practice Address - Street 1:3724 COOK AVE APT B
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63113-3837
Practice Address - Country:US
Practice Address - Phone:314-299-5147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-26
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0000000000Medicaid