Provider Demographics
NPI:1770030025
Name:BROADWAY, BRANDY
Entity Type:Individual
Prefix:
First Name:BRANDY
Middle Name:
Last Name:BROADWAY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 GLADIOLA DR
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-6140
Mailing Address - Country:US
Mailing Address - Phone:314-532-9057
Mailing Address - Fax:
Practice Address - Street 1:860 GLADIOLA DR
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-6140
Practice Address - Country:US
Practice Address - Phone:314-532-9057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-03
Last Update Date:2016-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015002240163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse