Provider Demographics
NPI:1477266849
Name:BROADES, CALANDRA TAHNEE
Entity Type:Individual
Prefix:
First Name:CALANDRA
Middle Name:TAHNEE
Last Name:BROADES
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 1:5067 MADRE MESA DR APT 2015
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89108-3592
Mailing Address - Country:US
Mailing Address - Phone:903-280-5025
Mailing Address - Fax:
Practice Address - Street 1:5067 MADRE MESA DR APT 2015
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89108-3592
Practice Address - Country:US
Practice Address - Phone:903-280-5025
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-02
Last Update Date:2023-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV2022642425335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV884365835Medicaid