Provider Demographics
NPI:1598947863
Name:BROADWATER, SHARONDA (LPN)
Entity Type:Individual
Prefix:MRS
First Name:SHARONDA
Middle Name:
Last Name:BROADWATER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 RODESSA RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14616-4606
Mailing Address - Country:US
Mailing Address - Phone:585-467-5996
Mailing Address - Fax:
Practice Address - Street 1:126 RODESSA RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14616-4606
Practice Address - Country:US
Practice Address - Phone:585-467-5996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-28
Last Update Date:2007-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2794091164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02868124Medicaid