Basic Information
| Provider Information | |||||||||
| NPI: | 1588014567 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BRODEUR | ||||||||
| FirstName: | ASHLEY | ||||||||
| MiddleName: | |||||||||
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| Credential: | CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 415348 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022415348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002258885 | ||||||||
| FaxNumber: | 5083341977 | ||||||||
| Practice Location | |||||||||
| Address1: | 55 LAKE AVE N | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016550002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083343452 | ||||||||
| FaxNumber: | 7744423477 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2016 | ||||||||
| LastUpdateDate: | 03/16/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN2267270 | MA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LA2100X | RN2267270 | MA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 110117297A | 05 | MA | MEDICAID |