Provider Demographics
NPI:1023810041
Name:CLEMMONS, BRODERICK EUGENE
Entity type:Individual
Prefix:
First Name:BRODERICK
Middle Name:EUGENE
Last Name:CLEMMONS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 N MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:IA
Mailing Address - Zip Code:52310-1227
Mailing Address - Country:US
Mailing Address - Phone:319-975-0285
Mailing Address - Fax:
Practice Address - Street 1:520 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:IA
Practice Address - Zip Code:52310-1227
Practice Address - Country:US
Practice Address - Phone:319-975-0285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-27
Last Update Date:2025-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide