Provider Demographics
NPI:1952023459
Name:BROEDERDORF, KELLY M (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:BROEDERDORF
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3707 DOTY RD STE CANDD
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:IL
Mailing Address - Zip Code:60098-7530
Mailing Address - Country:US
Mailing Address - Phone:815-338-6600
Mailing Address - Fax:815-206-1086
Practice Address - Street 1:3707 DOTY RD STE CANDD
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:IL
Practice Address - Zip Code:60098-7530
Practice Address - Country:US
Practice Address - Phone:815-338-6600
Practice Address - Fax:815-206-1086
Is Sole Proprietor?:No
Enumeration Date:2022-09-13
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.387373163WX0200X
IL209-027210363LF0000X
IL209027210363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WX0200XNursing Service ProvidersRegistered NurseOncology
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily