Provider Demographics
NPI:1821620212
Name:BROEDELL, AMANDA C
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:C
Last Name:BROEDELL
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 1:10860 SE SEMINOLE RD
Mailing Address - Street 2:
Mailing Address - City:TEQUESTA
Mailing Address - State:FL
Mailing Address - Zip Code:33469-8101
Mailing Address - Country:US
Mailing Address - Phone:561-307-4909
Mailing Address - Fax:
Practice Address - Street 1:1745 S IMPERIAL AVE
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-4243
Practice Address - Country:US
Practice Address - Phone:760-353-5130
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-04
Last Update Date:2020-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77148183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist