Provider Demographics
NPI:1528488087
Name:BRODHEAD, SARAH ELIZABETH (NP)
Entity type:Individual
Prefix:MISS
First Name:SARAH
Middle Name:ELIZABETH
Last Name:BRODHEAD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 AVENUE F UNIT A
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-5150
Mailing Address - Country:US
Mailing Address - Phone:310-995-6960
Mailing Address - Fax:
Practice Address - Street 1:2650 S BRISTOL ST STE 101
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92704-5751
Practice Address - Country:US
Practice Address - Phone:714-754-1444
Practice Address - Fax:714-754-7009
Is Sole Proprietor?:No
Enumeration Date:2014-04-23
Last Update Date:2014-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95000491363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP95000491OtherNURSE PRACTITIONER LICENSE NUMBER