Basic Information
| Provider Information | |||||||||
| NPI: | 1265002554 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROADWAY | ||||||||
| FirstName: | DIANA | ||||||||
| MiddleName: | MARIE | ||||||||
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| Credential: | APRN-CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9313 MEDICAL PLAZA DR STE 202 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294069176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435721200 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9313 MEDICAL PLAZA DR STE 202 | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294069176 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435721200 | ||||||||
| FaxNumber: | 8435530424 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2021 | ||||||||
| LastUpdateDate: | 05/19/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 216506 | AR | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LF0000X | 25919 | SC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.