Provider Demographics
NPI:1194497180
Name:BRODERICK, MACKENZIE LAUREN HANNAH
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:LAUREN HANNAH
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 W AVENUE J STE 300
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-2944
Mailing Address - Country:US
Mailing Address - Phone:661-341-3495
Mailing Address - Fax:
Practice Address - Street 1:1216 W AVENUE J STE 300
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2944
Practice Address - Country:US
Practice Address - Phone:661-341-3495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-29
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program