Provider Demographics
NPI:1487801817
Name:BRODERICK, KRISTY ROSE (FNP-BC)
Entity type:Individual
Prefix:MS
First Name:KRISTY
Middle Name:ROSE
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:KRISTY
Other - Middle Name:ROSE
Other - Last Name:ABDOU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-BC
Mailing Address - Street 1:200 W ARBOR DR DEPT 8220
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-8220
Mailing Address - Country:US
Mailing Address - Phone:619-929-0878
Mailing Address - Fax:
Practice Address - Street 1:200 W ARBOR DR DEPT 8220
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-8220
Practice Address - Country:US
Practice Address - Phone:619-840-4432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR200441107RN163W00000X
CA19601363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse