Provider Demographics
NPI:1750531711
Name:BROADBENT, MICHELLE L (NP)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
Last Name:BROADBENT
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 1:380 W PALMETTO PARK RD UNIT 408C
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33432-6719
Mailing Address - Country:US
Mailing Address - Phone:601-669-1038
Mailing Address - Fax:
Practice Address - Street 1:603 HAIFLEIGH ST
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:LA
Practice Address - Zip Code:70538-3734
Practice Address - Country:US
Practice Address - Phone:337-828-9092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-26
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA08068363LF0000X
FL9468755363LF0000X
MSR855964363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily