Provider Demographics
NPI:1235808213
Name:BROADNAX, DELESA R
Entity Type:Individual
Prefix:
First Name:DELESA
Middle Name:R
Last Name:BROADNAX
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 1:5122 GLENCROSSING WAY
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45238-3361
Mailing Address - Country:US
Mailing Address - Phone:513-827-9044
Mailing Address - Fax:513-832-1332
Practice Address - Street 1:5122 GLENCROSSING WAY
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45238-3361
Practice Address - Country:US
Practice Address - Phone:513-827-9044
Practice Address - Fax:513-832-1332
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-13
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN156549163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)