Provider Demographics
NPI:1568755478
Name:BROADNEAUX, NIKKI (PHARMD)
Entity Type:Individual
Prefix:DR
First Name:NIKKI
Middle Name:
Last Name:BROADNEAUX
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 180
Mailing Address - Street 2:
Mailing Address - City:PINE LAKE
Mailing Address - State:GA
Mailing Address - Zip Code:30072-0180
Mailing Address - Country:US
Mailing Address - Phone:414-418-0530
Mailing Address - Fax:
Practice Address - Street 1:477 TALLWOOD DR
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-4461
Practice Address - Country:US
Practice Address - Phone:414-418-0530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-25
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA021146183500000X
FLPS 32935183500000X
WI12969-40183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist