Provider Demographics
NPI:1063966984
Name:BROADWATER, ALYSSA REAU (MS, RD, LD, CSCS)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:REAU
Last Name:BROADWATER
Suffix:
Gender:F
Credentials:MS, RD, LD, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 KENNY LN
Mailing Address - Street 2:
Mailing Address - City:CARDINGTON
Mailing Address - State:OH
Mailing Address - Zip Code:43315-9611
Mailing Address - Country:US
Mailing Address - Phone:937-642-9037
Mailing Address - Fax:
Practice Address - Street 1:4353 TULLER RD STE K
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:OH
Practice Address - Zip Code:43017-5071
Practice Address - Country:US
Practice Address - Phone:937-642-9037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-09
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH8024133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered