Provider Demographics
NPI:1285935726
Name:BROADNAX, MUZIQUE LATISE (CMT, MMP,LMT,CA)
Entity type:Individual
Prefix:MS
First Name:MUZIQUE
Middle Name:LATISE
Last Name:BROADNAX
Suffix:
Gender:F
Credentials:CMT, MMP,LMT,CA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 E WASHINGTON ST STE 300
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85034-1908
Mailing Address - Country:US
Mailing Address - Phone:612-486-2775
Mailing Address - Fax:
Practice Address - Street 1:2915 WAYZATA BLVD
Practice Address - Street 2:304
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55405-2145
Practice Address - Country:US
Practice Address - Phone:612-396-2016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-16
Last Update Date:2021-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN938479175L00000X
AZMT-27885225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No175L00000XOther Service ProvidersHomeopath