Provider Demographics
NPI:1851170476
Name:BROOME, ISONYA TIERRA
Entity Type:Individual
Prefix:MS
First Name:ISONYA
Middle Name:TIERRA
Last Name:BROOME
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 1:2901 WEST BLVD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-6775
Mailing Address - Country:US
Mailing Address - Phone:843-337-1425
Mailing Address - Fax:
Practice Address - Street 1:2901 WEST BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-6775
Practice Address - Country:US
Practice Address - Phone:843-337-1425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-22
Last Update Date:2023-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC293D00000X, 332U00000X, 146D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
No293D00000XLaboratoriesPhysiological Laboratory
No332U00000XSuppliersHome Delivered Meals