Provider Demographics
NPI:1639890296
Name:BROADWAY, ALEXANDRIA DANIELLE (CNM)
Entity Type:Individual
Prefix:
First Name:ALEXANDRIA
Middle Name:DANIELLE
Last Name:BROADWAY
Suffix:
Gender:F
Credentials:CNM
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 919771
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:239-278-3600
Mailing Address - Fax:239-479-5202
Practice Address - Street 1:11100 SUMMER RIDGE LN
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-4064
Practice Address - Country:US
Practice Address - Phone:844-342-7935
Practice Address - Fax:239-479-5194
Is Sole Proprietor?:No
Enumeration Date:2022-09-12
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11021684367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife