Provider Demographics
NPI:1558939769
Name:BRODNAX, TENEKA RENEA
Entity Type:Individual
Prefix:
First Name:TENEKA
Middle Name:RENEA
Last Name:BRODNAX
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 1:5728 STAGE RD STE 5
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38134-4568
Mailing Address - Country:US
Mailing Address - Phone:901-590-3832
Mailing Address - Fax:
Practice Address - Street 1:5728 STAGE RD STE 5
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38134-4568
Practice Address - Country:US
Practice Address - Phone:901-590-3832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNI000000028682372600000X
I000000028682372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNL000000028682OtherSTATE LICENSE