Provider Demographics
NPI:1124992722
Name:BROADWAY, LATAIJA
Entity type:Individual
Prefix:
First Name:LATAIJA
Middle Name:
Last Name: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 1:5348 N 64TH ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68104-1534
Mailing Address - Country:US
Mailing Address - Phone:402-306-8731
Mailing Address - Fax:402-517-6841
Practice Address - Street 1:5348 N 64TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68104-1534
Practice Address - Country:US
Practice Address - Phone:402-306-8731
Practice Address - Fax:402-517-6841
Is Sole Proprietor?:No
Enumeration Date:2025-10-06
Last Update Date:2025-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE376J00000X
374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker