Provider Demographics
NPI:1871389189
Name:BROADWATER, KELLEY
Entity type:Individual
Prefix:
First Name:KELLEY
Middle Name:
Last Name:BROADWATER
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8093 MARIGOLD RD NE
Mailing Address - Street 2:
Mailing Address - City:KENSINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:44427-9625
Mailing Address - Country:US
Mailing Address - Phone:330-206-4163
Mailing Address - Fax:
Practice Address - Street 1:8093 MARIGOLD RD NE
Practice Address - Street 2:
Practice Address - City:KENSINGTON
Practice Address - State:OH
Practice Address - Zip Code:44427-9625
Practice Address - Country:US
Practice Address - Phone:330-206-4163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-15
Last Update Date:2025-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker