Provider Demographics
NPI:1831434406
Name:BRODIE, WALTER (RN BSN)
Entity type:Individual
Prefix:MR
First Name:WALTER
Middle Name:
Last Name:BRODIE
Suffix:
Gender:M
Credentials:RN BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 S LAVENTURE RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98274-6034
Mailing Address - Country:US
Mailing Address - Phone:360-428-6125
Mailing Address - Fax:360-428-6164
Practice Address - Street 1:1514 S LAVENTURE RD
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98274-6034
Practice Address - Country:US
Practice Address - Phone:360-428-6125
Practice Address - Fax:360-428-6164
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-07
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN 00085749163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool