Provider Demographics
NPI:1255104725
Name:BRODEUR, EMILLY MIKAL (ARNP)
Entity type:Individual
Prefix:
First Name:EMILLY
Middle Name:MIKAL
Last Name:BRODEUR
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:627 HODGIN RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:52336-9715
Mailing Address - Country:US
Mailing Address - Phone:319-431-6699
Mailing Address - Fax:
Practice Address - Street 1:1791 HIGHWAY 64 E
Practice Address - Street 2:
Practice Address - City:ANAMOSA
Practice Address - State:IA
Practice Address - Zip Code:52205-2112
Practice Address - Country:US
Practice Address - Phone:319-462-3571
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-06
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA176973363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily