Provider Demographics
NPI:1710639497
Name:BROADWAY, ADRIAN (REGISTERED NURSE)
Entity Type:Individual
Prefix:MS
First Name:ADRIAN
Middle Name:
Last Name:BROADWAY
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 LONG CREEK WAY
Mailing Address - Street 2:
Mailing Address - City:GROVETOWN
Mailing Address - State:GA
Mailing Address - Zip Code:30813-5275
Mailing Address - Country:US
Mailing Address - Phone:706-951-4262
Mailing Address - Fax:
Practice Address - Street 1:103 LONG CREEK WAY
Practice Address - Street 2:
Practice Address - City:GROVETOWN
Practice Address - State:GA
Practice Address - Zip Code:30813-5275
Practice Address - Country:US
Practice Address - Phone:706-951-4262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-24
Last Update Date:2022-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN184223163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN184223OtherNURSING LICENSE