Provider Demographics
NPI:1649410051
Name:BROOMFIELD, CHARITY (IDC)
Entity Type:Individual
Prefix:MS
First Name:CHARITY
Middle Name:
Last Name:BROOMFIELD
Suffix:
Gender:F
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 HARRIS ROAD
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23702
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:USS BULKELEY
Practice Address - Street 2:DDG 84, UIC 22992
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09565-1301
Practice Address - Country:US
Practice Address - Phone:757-445-6147
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-25
Last Update Date:2009-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman