Provider Demographics
NPI:1841615796
Name:BROOM, CAROL
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:BROOM
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 1:312 DOWELL RD
Mailing Address - Street 2:
Mailing Address - City:ROCKWALL
Mailing Address - State:TX
Mailing Address - Zip Code:75032-7172
Mailing Address - Country:US
Mailing Address - Phone:972-948-7949
Mailing Address - Fax:
Practice Address - Street 1:992 E US HIGHWAY 80
Practice Address - Street 2:
Practice Address - City:FORNEY
Practice Address - State:TX
Practice Address - Zip Code:75126-8709
Practice Address - Country:US
Practice Address - Phone:972-552-2920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-03
Last Update Date:2014-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX737648363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily