Provider Demographics
NPI:1972076354
Name:BROADWAY, ANGELA MORRIS (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:MORRIS
Last Name:BROADWAY
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:342 S SALISBURY ST
Mailing Address - Street 2:
Mailing Address - City:MOCKSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27028-2526
Mailing Address - Country:US
Mailing Address - Phone:336-940-7664
Mailing Address - Fax:336-940-7664
Practice Address - Street 1:342 S SALISBURY ST
Practice Address - Street 2:
Practice Address - City:MOCKSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27028-2526
Practice Address - Country:US
Practice Address - Phone:336-940-7664
Practice Address - Fax:336-940-7664
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-08
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC281469163WH0200X, 163WI0500X, 163WM0705X, 163WP0200X, 208000000X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics