Provider Demographics
NPI:1003383688
Name:BROADDUS, LATRICIA
Entity Type:Individual
Prefix:
First Name:LATRICIA
Middle Name:
Last Name:BROADDUS
Suffix:
Gender:F
Credentials:
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 13
Mailing Address - Street 2:
Mailing Address - City:SAINT STEPHENS CHURCH
Mailing Address - State:VA
Mailing Address - Zip Code:23148-0013
Mailing Address - Country:US
Mailing Address - Phone:804-664-2271
Mailing Address - Fax:
Practice Address - Street 1:5833 RICHMOND TAPPAHANNOCK HWY STE 106B
Practice Address - Street 2:
Practice Address - City:AYLETT
Practice Address - State:VA
Practice Address - Zip Code:23009-3007
Practice Address - Country:US
Practice Address - Phone:042-230-0298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-31
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024181570363LP0808X
253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0732762767Medicaid