Provider Demographics
NPI:1760791768
Name:BRODSKY, TATIANA
Entity Type:Individual
Prefix:
First Name:TATIANA
Middle Name:
Last Name:BRODSKY
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 1:4250 NABAL DR
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-7169
Mailing Address - Country:US
Mailing Address - Phone:619-813-9042
Mailing Address - Fax:
Practice Address - Street 1:4250 NABAL DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-7169
Practice Address - Country:US
Practice Address - Phone:619-813-9042
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-25
Last Update Date:2010-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA250072164X00000X
CA00671706376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No376K00000XNursing Service Related ProvidersNurse's Aide