Provider Demographics
NPI:1649043753
Name:MILLER, BRODA L (LPN)
Entity type:Individual
Prefix:
First Name:BRODA
Middle Name:L
Last Name:MILLER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:BRODA
Other - Middle Name:L
Other - Last Name:HOLLOWAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1601 OLD SOUTH RIVER RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303-4120
Mailing Address - Country:US
Mailing Address - Phone:636-224-1210
Mailing Address - Fax:636-246-1008
Practice Address - Street 1:639 YORK ST RM 212
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-3919
Practice Address - Country:US
Practice Address - Phone:217-222-6277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-31
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043089365164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse