Provider Demographics
NPI:1033655105
Name:BROADBRIDGE, MELANIE ELAINE (AA-C)
Entity type:Individual
Prefix:MS
First Name:MELANIE
Middle Name:ELAINE
Last Name:BROADBRIDGE
Suffix:
Gender:F
Credentials:AA-C
Other - Prefix:MS
Other - First Name:MELANIE
Other - Middle Name:ELAINE
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AA-C
Mailing Address - Street 1:3100 SPRING FOREST RD STE 120
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-2880
Mailing Address - Country:US
Mailing Address - Phone:336-953-7203
Mailing Address - Fax:
Practice Address - Street 1:1900 KILDAIRE FARM RD
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-6616
Practice Address - Country:US
Practice Address - Phone:363-953-7203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-13
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1000-00840367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant