Provider Demographics
NPI:1265002554
Name:BROADWAY, DIANA MARIE (APRN-CNP)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:MARIE
Last Name:BROADWAY
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9313 MEDICAL PLAZA DR STE 202
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406-9176
Mailing Address - Country:US
Mailing Address - Phone:843-572-1200
Mailing Address - Fax:
Practice Address - Street 1:9313 MEDICAL PLAZA DR STE 202
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9176
Practice Address - Country:US
Practice Address - Phone:843-572-1200
Practice Address - Fax:843-553-0424
Is Sole Proprietor?:No
Enumeration Date:2021-06-29
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR216506363LF0000X
SC25919363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily