Provider Demographics
NPI:1679941561
Name:BRODBECK, RAEANN LYNN (APRN)
Entity type:Individual
Prefix:MRS
First Name:RAEANN
Middle Name:LYNN
Last Name:BRODBECK
Suffix:
Gender:
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8900 YANKEE RD
Mailing Address - Street 2:
Mailing Address - City:OTTAWA LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49267-9554
Mailing Address - Country:US
Mailing Address - Phone:734-888-1135
Mailing Address - Fax:
Practice Address - Street 1:30000 E RIVER RD
Practice Address - Street 2:
Practice Address - City:PERRYSBURG
Practice Address - State:OH
Practice Address - Zip Code:43551-3429
Practice Address - Country:US
Practice Address - Phone:419-931-3440
Practice Address - Fax:419-661-4020
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-09
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4074250685363LF0000X
OHCOA.18416-NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0162645Medicaid
OH391010Medicare Oscar/Certification