Provider Demographics
NPI:1194409748
Name:BROADEN, LETRELLE DIANE
Entity type:Individual
Prefix:
First Name:LETRELLE
Middle Name:DIANE
Last Name:BROADEN
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 1:100 BATEY CIR STE C
Mailing Address - Street 2:
Mailing Address - City:DICKSON
Mailing Address - State:TN
Mailing Address - Zip Code:37055-1044
Mailing Address - Country:US
Mailing Address - Phone:517-410-1857
Mailing Address - Fax:931-236-0024
Practice Address - Street 1:100 BATEY CIR STE C
Practice Address - Street 2:
Practice Address - City:DICKSON
Practice Address - State:TN
Practice Address - Zip Code:37055-1044
Practice Address - Country:US
Practice Address - Phone:877-676-1399
Practice Address - Fax:931-236-0024
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-14
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle