Provider Demographics
NPI:1134164205
Name:BROADWATER, HOLLY RENEE (FNP)
Entity type:Individual
Prefix:
First Name:HOLLY
Middle Name:RENEE
Last Name:BROADWATER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 MED TECH PKWY STE 200
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-4001
Mailing Address - Country:US
Mailing Address - Phone:423-232-6120
Mailing Address - Fax:
Practice Address - Street 1:101 MED TECH PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-4007
Practice Address - Country:US
Practice Address - Phone:423-232-6120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7703363LF0000X
TN0370804-222081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4078380OtherBLUE CROSS/BLUE SHIELD
TNP00102426OtherMEDICARE RAILROAD
TN1512908Medicaid
TN1512908Medicaid
TNTN0122OtherJOHN DEERE (JC)
TNTN0122OtherJOHN DEERE (JC)