Provider Demographics
NPI:1891493730
Name:BROOMER, RACHELLE PATRICE
Entity Type:Individual
Prefix:
First Name:RACHELLE
Middle Name:PATRICE
Last Name:BROOMER
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 1:4947 N HARBOR ISLES DR
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33312-5918
Mailing Address - Country:US
Mailing Address - Phone:516-242-4505
Mailing Address - Fax:
Practice Address - Street 1:4947 N HARBOR ISLES DR
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33312-5918
Practice Address - Country:US
Practice Address - Phone:516-242-4505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-20
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9431961163WE0003X
FL11002521363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WE0003XNursing Service ProvidersRegistered NurseEmergency