Provider Demographics
NPI:1124308689
Name:BRODERSON, NICOLE (RN, MSN, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:BRODERSON
Suffix:
Gender:F
Credentials:RN, MSN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 23901
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87502-3901
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
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-27
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-01815363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health