Provider Demographics
NPI:1811132475
Name:BRODERICK, LAURA KAY
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:KAY
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 N EVERGREEN CIR
Mailing Address - Street 2:
Mailing Address - City:HARTLAND
Mailing Address - State:WI
Mailing Address - Zip Code:53029-8636
Mailing Address - Country:US
Mailing Address - Phone:262-369-9011
Mailing Address - Fax:
Practice Address - Street 1:1755 N BARKER RD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-1801
Practice Address - Country:US
Practice Address - Phone:262-821-3939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-11
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI722026174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI722026OtherSTATE LICENSE
WI40649500Medicaid