Provider Demographics
NPI:1528411642
Name:BROADNAX, TIFFANY (CMA)
Entity Type:Individual
Prefix:
First Name:TIFFANY
Middle Name:
Last Name:BROADNAX
Suffix:
Gender:F
Credentials:CMA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 ASH ST
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NC
Mailing Address - Zip Code:27288-4829
Mailing Address - Country:US
Mailing Address - Phone:336-589-9833
Mailing Address - Fax:
Practice Address - Street 1:1100 E WENDOVER AVE
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27405-6713
Practice Address - Country:US
Practice Address - Phone:336-641-4592
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-14
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2404435172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker