Provider Demographics
NPI:1114140696
Name:BROADOUS, LISA DENISE
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:DENISE
Last Name:BROADOUS
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 1:6903 N ALBINA AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97217-1603
Mailing Address - Country:US
Mailing Address - Phone:503-415-1892
Mailing Address - Fax:
Practice Address - Street 1:2330 NE SISKIYOU ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212-2471
Practice Address - Country:US
Practice Address - Phone:503-528-0757
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion