Individual
STACEY T. BROECKER
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
O.D.
Contact information
Practice address
2356 UNIVERSITY AVE W, SAINT PAUL, MN 55114-1897
(651) 645-8124
(651) 645-8125
Mailing address
2356 UNIVERSITY AVE W, SAINT PAUL, MN 55114-1897
(651) 645-8124
(651) 645-8125
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
2108
MN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
808023200
—
MN
Enumeration date
05/24/2006
Last updated
11/20/2018
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