Provider Demographics
NPI:1972963155
Name:BROADNAX, SHAMEKA NICOLE MASON
Entity Type:Individual
Prefix:
First Name:SHAMEKA
Middle Name:NICOLE MASON
Last Name:BROADNAX
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 1:2238 IOWA ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-1930
Mailing Address - Country:US
Mailing Address - Phone:912-713-8178
Mailing Address - Fax:
Practice Address - Street 1:1395 EISENHOWER DR
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-3901
Practice Address - Country:US
Practice Address - Phone:912-356-2157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-01
Last Update Date:2016-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN221070163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse