Provider Demographics
NPI:1699526723
Name:BRODERICK, SHERILL ALETHIA (NP)
Entity type:Individual
Prefix:MISS
First Name:SHERILL
Middle Name:ALETHIA
Last Name:BRODERICK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MISS
Other - First Name:SHERILL
Other - Middle Name:ALETHIA
Other - Last Name:BRODERICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NP
Mailing Address - Street 1:3650 LILLY BROOK DR
Mailing Address - Street 2:
Mailing Address - City:LOGANVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30052-3391
Mailing Address - Country:US
Mailing Address - Phone:201-898-8574
Mailing Address - Fax:
Practice Address - Street 1:3650 LILLY BROOK DR
Practice Address - Street 2:
Practice Address - City:LOGANVILLE
Practice Address - State:GA
Practice Address - Zip Code:30052-3391
Practice Address - Country:US
Practice Address - Phone:201-580-0480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2023190695363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health