Provider Demographics
NPI:1740297498
Name:BROOM, JANET L (MSN, APRN-BC)
Entity type:Individual
Prefix:MRS
First Name:JANET
Middle Name:L
Last Name:BROOM
Suffix:
Gender:F
Credentials:MSN, APRN-BC
Other - Prefix:MRS
Other - First Name:JANET
Other - Middle Name:L
Other - Last Name:MCEWEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, APRN-BC
Mailing Address - Street 1:1275 HAWTHORN RD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:IL
Mailing Address - Zip Code:62881-1028
Mailing Address - Country:US
Mailing Address - Phone:618-548-4545
Mailing Address - Fax:618-548-4577
Practice Address - Street 1:1275 HAWTHORN RD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:IL
Practice Address - Zip Code:62881-1028
Practice Address - Country:US
Practice Address - Phone:618-548-4545
Practice Address - Fax:618-548-4577
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.00 8351363LA2200X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO427355003Medicaid
MO427355003Medicaid
841622616Medicare ID - Type Unspecified