Provider Demographics
NPI:1558659391
Name:BROADWELL, GEORGIANNA (LD)
Entity Type:Individual
Prefix:
First Name:GEORGIANNA
Middle Name:
Last Name:BROADWELL
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 E DERENNE AVE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31405-6736
Mailing Address - Country:US
Mailing Address - Phone:912-644-5300
Mailing Address - Fax:912-644-5260
Practice Address - Street 1:315 EISENHOWER DR
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-2605
Practice Address - Country:US
Practice Address - Phone:912-355-9220
Practice Address - Fax:912-234-7789
Is Sole Proprietor?:No
Enumeration Date:2011-07-14
Last Update Date:2011-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD003146133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered