Provider Demographics
NPI:1538718770
Name:BROADNAX, CAROLYN ANN
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:ANN
Last Name:BROADNAX
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 1:3524 CEDAR SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28027
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3524 CEDAR SPRINGS DR
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28027
Practice Address - Country:US
Practice Address - Phone:704-652-2131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider