Provider Demographics
NPI:1649456047
Name:BRODEUR, NICOLE L (NP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:BRODEUR
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16182 PEBBLESTONE CV
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75035-1630
Mailing Address - Country:US
Mailing Address - Phone:214-505-0955
Mailing Address - Fax:
Practice Address - Street 1:865 JUNCTION DR
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-5006
Practice Address - Country:US
Practice Address - Phone:214-547-8300
Practice Address - Fax:214-547-9787
Is Sole Proprietor?:No
Enumeration Date:2008-01-15
Last Update Date:2024-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX699527363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX193397001Medicaid
TX193397002Medicaid
TX193397003Medicaid
TX8K7370Medicare PIN
TX8K7374Medicare PIN
TX8K7377Medicare PIN