Provider Demographics
NPI:1699183954
Name:BROADWAY, TILA (WHNP-BC)
Entity Type:Individual
Prefix:
First Name:TILA
Middle Name:
Last Name:BROADWAY
Suffix:
Gender:F
Credentials:WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23802 HIGHWAY 59 N
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:77339-1510
Mailing Address - Country:US
Mailing Address - Phone:281-312-5400
Mailing Address - Fax:281-312-5440
Practice Address - Street 1:23802 HIGHWAY 59 N
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:TX
Practice Address - Zip Code:77339-1510
Practice Address - Country:US
Practice Address - Phone:281-312-5400
Practice Address - Fax:281-312-5400
Is Sole Proprietor?:No
Enumeration Date:2014-07-30
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP125930363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8104NKOtherBCBS
TX8104NKOtherBCBS