Provider Demographics
NPI:1629755657
Name:BRODERICK, REBECCA (ACNPC-AG, BSN, RN)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:ACNPC-AG, BSN, RN
Other - Prefix:
Other - First Name:REBECCA
Other - Middle Name:
Other - Last Name:BRODERICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:HOLMES
Mailing Address - Street 1:18824 MOUNTAIN POINT DR
Mailing Address - Street 2:
Mailing Address - City:EAGLE RIVER
Mailing Address - State:AK
Mailing Address - Zip Code:99577-8555
Mailing Address - Country:US
Mailing Address - Phone:703-447-6155
Mailing Address - Fax:
Practice Address - Street 1:677 WOODLAND SQUARE LOOP SE STE D7
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-1000
Practice Address - Country:US
Practice Address - Phone:703-447-6155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-30
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61413663-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner