Provider Demographics
NPI:1124765714
Name:BROADAWAY, SELINA LOUISE (CPNP-AC)
Entity type:Individual
Prefix:MRS
First Name:SELINA
Middle Name:LOUISE
Last Name:BROADAWAY
Suffix:
Gender:F
Credentials:CPNP-AC
Other - Prefix:
Other - First Name:SELINA
Other - Middle Name:LOUISE
Other - Last Name:RIBNICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:848 ADAMS AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-2816
Mailing Address - Country:US
Mailing Address - Phone:901-661-3719
Mailing Address - Fax:
Practice Address - Street 1:262 DANNY THOMAS PL
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38105-3678
Practice Address - Country:US
Practice Address - Phone:888-226-4343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-16
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN31660363LP0222X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0222XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics, Critical Care