Provider Demographics
NPI:1922437003
Name:WATHEN BROADWAY, PATRICIA
Entity Type:Individual
Prefix:MRS
First Name:PATRICIA
Middle Name:
Last Name:WATHEN 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 1:1326 11TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:FL
Mailing Address - Zip Code:34769-3709
Mailing Address - Country:US
Mailing Address - Phone:407-892-9000
Mailing Address - Fax:407-892-9000
Practice Address - Street 1:1326 11TH ST
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:FL
Practice Address - Zip Code:34769-3709
Practice Address - Country:US
Practice Address - Phone:407-892-9000
Practice Address - Fax:407-892-9000
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-08
Last Update Date:2013-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAS4944332S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332S00000XSuppliersHearing Aid Equipment