Provider Demographics
NPI:1720749229
Name:BRODERICK, MARY SIOBHAN (RN, CDCES)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:SIOBHAN
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:RN, CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:164 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BATAVIA
Mailing Address - State:NY
Mailing Address - Zip Code:14020-2113
Mailing Address - Country:US
Mailing Address - Phone:585-344-5331
Mailing Address - Fax:
Practice Address - Street 1:164 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:BATAVIA
Practice Address - State:NY
Practice Address - Zip Code:14020-2113
Practice Address - Country:US
Practice Address - Phone:585-344-5331
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-06
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY749791163W00000X, 163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator
No163W00000XNursing Service ProvidersRegistered Nurse