Provider Demographics
NPI:1881023828
Name:BROADAWAY, MALLORY LEEANN (APRN-CNP)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:LEEANN
Last Name:BROADAWAY
Suffix:
Gender:F
Credentials:APRN-CNP
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:LEEANN
Other - Last Name:BROADAWAY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CNP
Mailing Address - Street 1:1815 PLEASANT GROVE ROAD
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-7870
Mailing Address - Country:US
Mailing Address - Phone:870-933-6886
Mailing Address - Fax:870-933-9395
Practice Address - Street 1:1704 HIGHWAY 69 WEST
Practice Address - Street 2:
Practice Address - City:TRUMANN
Practice Address - State:AR
Practice Address - Zip Code:72472-2029
Practice Address - Country:US
Practice Address - Phone:870-483-4003
Practice Address - Fax:870-483-4009
Is Sole Proprietor?:No
Enumeration Date:2013-11-08
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA003980363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR201676758Medicaid
AR5PA17OtherBCBS
AR5PA17OtherBCBS