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:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29373 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-7005
Mailing Address - Country:US
Mailing Address - Phone:847-390-5900
Mailing Address - Fax:
Practice Address - Street 1:100 VILLAGE GRN STE 120
Practice Address - Street 2:
Practice Address - City:LINCOLNSHIRE
Practice Address - State:IL
Practice Address - Zip Code:60069-3095
Practice Address - Country:US
Practice Address - Phone:847-634-1766
Practice Address - Fax:847-634-2894
Is Sole Proprietor?:No
Enumeration Date:2022-09-13
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-027210363LF0000X
IL041.387373163WX0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WX0200XNursing Service ProvidersRegistered NurseOncology