Provider Demographics
NPI:1629444823
Name:BRODERICK, STEPHANIE LAUREN (CNM, WHNP-BC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LAUREN
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:CNM, WHNP-BC
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:LAUREN
Other - Last Name:WAGGONER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:400 N HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60506-3814
Mailing Address - Country:US
Mailing Address - Phone:630-892-4355
Mailing Address - Fax:630-892-0262
Practice Address - Street 1:1400 INDIAN AVE
Practice Address - Street 2:
Practice Address - City:AURORA
Practice Address - State:IL
Practice Address - Zip Code:60505-3137
Practice Address - Country:US
Practice Address - Phone:630-892-4355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-11
Last Update Date:2022-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209013055363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology