Provider Demographics
NPI:1285828715
Name:BROADWAY, AMANDA (RNFA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:BROADWAY
Suffix:
Gender:F
Credentials:RNFA
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 247
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39441-0247
Mailing Address - Country:US
Mailing Address - Phone:601-399-6167
Mailing Address - Fax:601-399-6281
Practice Address - Street 1:1007 JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4350
Practice Address - Country:US
Practice Address - Phone:601-649-7802
Practice Address - Fax:601-428-7841
Is Sole Proprietor?:No
Enumeration Date:2007-08-28
Last Update Date:2014-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR866035163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant