Provider Demographics
NPI:1285811737
Name:BROADIE, SHANNON DEE
Entity type:Individual
Prefix:
First Name:SHANNON
Middle Name:DEE
Last Name:BROADIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:SHANNON
Other - Middle Name:DEE
Other - Last Name:CAMERON-BROADIE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:721 E GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:PONCA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:74601-5513
Mailing Address - Country:US
Mailing Address - Phone:580-749-5139
Mailing Address - Fax:
Practice Address - Street 1:721 E GRAND AVE
Practice Address - Street 2:
Practice Address - City:PONCA CITY
Practice Address - State:OK
Practice Address - Zip Code:74601-5513
Practice Address - Country:US
Practice Address - Phone:580-749-5139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-28
Last Update Date:2008-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKR0085845163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse