Basic Information
Provider Information | |||||||||
NPI: | 1225093636 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRODZINSKI | ||||||||
FirstName: | CAREY | ||||||||
MiddleName: | J | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 165 SHERMAN DR | ||||||||
Address2: |   | ||||||||
City: | ST JOHNSBURY | ||||||||
State: | VT | ||||||||
PostalCode: | 058199811 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8027489405 | ||||||||
FaxNumber: | 8027484540 | ||||||||
Practice Location | |||||||||
Address1: | 185 SHERMAN DRIVE | ||||||||
Address2: | SUITE 1 | ||||||||
City: | ST JOHNSBURY | ||||||||
State: | VT | ||||||||
PostalCode: | 05819 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8027485041 | ||||||||
FaxNumber: | 8027485094 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/19/2006 | ||||||||
LastUpdateDate: | 09/20/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 1010020383 | VT | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | 101-0020383 | VT | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
ID | Type | State | Issuer | Description | 0NP2800 | 05 | VT |   | MEDICAID | P21615 | 01 | VT | MEDICARE PROVIDER NUMBER | OTHER |