Provider Demographics
NPI:1992269534
Name:BRODERSON, ANNE C (APRN, FNP-C)
Entity type:Individual
Prefix:MRS
First Name:ANNE
Middle Name:C
Last Name:BRODERSON
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 286
Mailing Address - Street 2:
Mailing Address - City:HOLUALOA
Mailing Address - State:HI
Mailing Address - Zip Code:96725-0286
Mailing Address - Country:US
Mailing Address - Phone:808-215-6574
Mailing Address - Fax:808-758-0043
Practice Address - Street 1:75-5699 KOPIKO ST UNIT 5
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-3651
Practice Address - Country:US
Practice Address - Phone:808-215-6574
Practice Address - Fax:808-758-0043
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-28
Last Update Date:2024-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIRN-63490163W00000X
HIAPRN-2600363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI830689Medicaid