Provider Demographics
NPI:1295470573
Name:DAWSON-BROADY, COREENA IRENE
Entity Type:Individual
Prefix:
First Name:COREENA
Middle Name:IRENE
Last Name:DAWSON-BROADY
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 1:914 W CAVANAUGH RD APT 9
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48910-6206
Mailing Address - Country:US
Mailing Address - Phone:517-604-3139
Mailing Address - Fax:
Practice Address - Street 1:405 W GREENLAWN AVE STE 200
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48910-2889
Practice Address - Country:US
Practice Address - Phone:517-657-2638
Practice Address - Fax:248-712-4381
Is Sole Proprietor?:No
Enumeration Date:2022-05-02
Last Update Date:2022-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist