Provider Demographics
NPI:1639942774
Name:BROADUS, AMBER D (CHW)
Entity Type:Individual
Prefix:
First Name:AMBER
Middle Name:D
Last Name:BROADUS
Suffix:
Gender:F
Credentials:CHW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1549 BRIARWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43211-1501
Mailing Address - Country:US
Mailing Address - Phone:614-783-8153
Mailing Address - Fax:
Practice Address - Street 1:1549 BRIARWOOD AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43211-1501
Practice Address - Country:US
Practice Address - Phone:614-783-8153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-31
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHJFRF-CNTSVC172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker