Provider Demographics
NPI:1295427052
Name:BROADWELL, MADISON (PMHNP)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:BROADWELL
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 W ILLINOIS AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-5808
Mailing Address - Country:US
Mailing Address - Phone:910-692-2444
Mailing Address - Fax:
Practice Address - Street 1:195 W ILLINOIS AVE
Practice Address - Street 2:
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387-5808
Practice Address - Country:US
Practice Address - Phone:910-692-2444
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5018127363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health