Provider Demographics
NPI:1780765735
Name:BROADDUS, CHARLENE SUE (ARNP)
Entity type:Individual
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First Name:CHARLENE
Middle Name:SUE
Last Name:BROADDUS
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Gender:F
Credentials:ARNP
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Mailing Address - Street 1:225 HOSPITAL DR
Mailing Address - Street 2:STE 300A
Mailing Address - City:WINCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40391-7604
Mailing Address - Country:US
Mailing Address - Phone:859-323-3976
Mailing Address - Fax:859-257-6060
Practice Address - Street 1:GILL HEART INSTITUTE 800 ROSE ST
Practice Address - Street 2:G100
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-0093
Practice Address - Country:US
Practice Address - Phone:859-323-0295
Practice Address - Fax:859-257-8699
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2016-07-20
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Provider Licenses
StateLicense IDTaxonomies
KY4695P363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7801709200Medicaid
KY446026Medicare PIN