Provider Demographics
NPI:1801852447
Name:BRODERICK, COLLEEN RUTH (NP)
Entity Type:Individual
Prefix:MS
First Name:COLLEEN
Middle Name:RUTH
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8453 S NAVAJO DR
Mailing Address - Street 2:
Mailing Address - City:SAFFORD
Mailing Address - State:AZ
Mailing Address - Zip Code:85546-7753
Mailing Address - Country:US
Mailing Address - Phone:928-792-7842
Mailing Address - Fax:
Practice Address - Street 1:711 S 14TH AVE
Practice Address - Street 2:STE B
Practice Address - City:SAFFORD
Practice Address - State:AZ
Practice Address - Zip Code:85546-3337
Practice Address - Country:US
Practice Address - Phone:480-318-5584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-22
Last Update Date:2012-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN000099282363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology