Provider Demographics
NPI:1033750401
Name:BROADHEAD, CORI CLARK
Entity Type:Individual
Prefix:
First Name:CORI
Middle Name:CLARK
Last Name:BROADHEAD
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 1:216 ELDER ST
Mailing Address - Street 2:
Mailing Address - City:IRONDALE
Mailing Address - State:AL
Mailing Address - Zip Code:35210-2504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:516 QUINTARD AVE
Practice Address - Street 2:
Practice Address - City:ANNISTON
Practice Address - State:AL
Practice Address - Zip Code:36201-5711
Practice Address - Country:US
Practice Address - Phone:256-741-9799
Practice Address - Fax:256-741-9795
Is Sole Proprietor?:No
Enumeration Date:2019-10-07
Last Update Date:2019-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL201914904363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics