Provider Demographics
NPI:1740433176
Name:BROADWELL, JOANNE LYNN (PTA)
Entity Type:Individual
Prefix:
First Name:JOANNE
Middle Name:LYNN
Last Name:BROADWELL
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 W 6TH ST
Mailing Address - Street 2:SUITE 140
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-2525
Mailing Address - Country:US
Mailing Address - Phone:315-564-7700
Mailing Address - Fax:
Practice Address - Street 1:140 W 6TH ST
Practice Address - Street 2:SUITE 140
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-2525
Practice Address - Country:US
Practice Address - Phone:315-564-7700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-29
Last Update Date:2008-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006082-1261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy