Basic Information
| Provider Information | |||||||||
| NPI: | 1952023459 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROEDERDORF | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | REGISTERED NURSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2031 GREENVIEW DR | ||||||||
| Address2: | |||||||||
| City: | WOODSTOCK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600987005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8474504496 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 801 S MILWAUKEE AVE | ||||||||
| Address2: | |||||||||
| City: | LIBERTYVILLE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600483204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8473622900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2022 | ||||||||
| LastUpdateDate: | 09/13/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WX0200X | 041.387373 | IL | Y | Nursing Service Providers | Registered Nurse | Oncology |
No ID Information.