1457898355 NPI number — BRIEENNA BRODDIE

Table of content: BRIEENNA BRODDIE (NPI 1457898355)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457898355 NPI number — BRIEENNA BRODDIE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRODDIE
Provider First Name:
BRIEENNA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457898355
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7320 SW HUNZIKER ST
Provider Second Line Business Mailing Address:
SUITE 203
Provider Business Mailing Address City Name:
TIGARD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97223-8283
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4956 DEMING RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEMING
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98244-9242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-383-2000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/30/2017

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 235Z00000X , with the licence number:  61666326 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2355S0801X , with the licence number: 0A0587 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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