Provider Demographics
NPI:1609463587
Name:BROADDRICK, JULIE VANG (FNP-C)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:VANG
Last Name:BROADDRICK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 334
Mailing Address - Street 2:
Mailing Address - City:BIXBY
Mailing Address - State:OK
Mailing Address - Zip Code:74008-0334
Mailing Address - Country:US
Mailing Address - Phone:918-943-3790
Mailing Address - Fax:
Practice Address - Street 1:11911 S MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:BIXBY
Practice Address - State:OK
Practice Address - Zip Code:74008-2030
Practice Address - Country:US
Practice Address - Phone:918-943-3790
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-28
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0118511207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine