Provider Demographics
NPI:1861135402
Name:BRODERICK, AMY (RN)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3489 ROBBIN CT
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARA
Mailing Address - State:UT
Mailing Address - Zip Code:84765-5306
Mailing Address - Country:US
Mailing Address - Phone:435-817-2541
Mailing Address - Fax:
Practice Address - Street 1:5381 S GREEN ST
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84123-4661
Practice Address - Country:US
Practice Address - Phone:435-817-2541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-04-20
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9641739-3102163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management