Provider Demographics
NPI:1316222797
Name:BROADDUS, DIANA PATTON (RN)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:PATTON
Last Name:BROADDUS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 EMERSON DRIVE
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:44904
Mailing Address - Country:US
Mailing Address - Phone:419-631-9259
Mailing Address - Fax:
Practice Address - Street 1:1710 EMERSON DR
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44904-1809
Practice Address - Country:US
Practice Address - Phone:419-631-9259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-17
Last Update Date:2011-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.313748163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse