Provider Demographics
NPI:1932473741
Name:NICOLE BRODERSON LLC
Entity Type:Organization
Organization Name:NICOLE BRODERSON LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:MISS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:R
Authorized Official - Last Name:BRODERSON
Authorized Official - Suffix:
Authorized Official - Credentials:CNP
Authorized Official - Phone:505-428-0072
Mailing Address - Street 1:1421 LUISA ST
Mailing Address - Street 2:SUITE N
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-4073
Mailing Address - Country:US
Mailing Address - Phone:505-428-0072
Mailing Address - Fax:888-256-1158
Practice Address - Street 1:1421 LUISA ST
Practice Address - Street 2:SUITE N
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-4073
Practice Address - Country:US
Practice Address - Phone:505-428-0072
Practice Address - Fax:888-256-1158
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-27
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMB2485490101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty