Provider Demographics
NPI:1154708956
Name:BROADWAY, SUSAN (RN, NP)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:BROADWAY
Suffix:
Gender:F
Credentials:RN, NP
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Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1 CYCLOTRON RD
Mailing Address - Street 2:MS26R0143
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94720-8099
Mailing Address - Country:US
Mailing Address - Phone:510-486-6951
Mailing Address - Fax:510-486-7192
Practice Address - Street 1:1 CYCLOTRON RD
Practice Address - Street 2:MS26R0143
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94720-8099
Practice Address - Country:US
Practice Address - Phone:510-486-6951
Practice Address - Fax:510-486-7192
Is Sole Proprietor?:No
Enumeration Date:2015-04-30
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA332697363LA2200X, 363LX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational Health