Provider Demographics
NPI:1316149628
Name:BROADNAX, CRYSTAL LYNNIA (MSN, RN)
Entity type:Individual
Prefix:MRS
First Name:CRYSTAL
Middle Name:LYNNIA
Last Name:BROADNAX
Suffix:
Gender:F
Credentials:MSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 BUCKNER AVE
Mailing Address - Street 2:
Mailing Address - City:FORT LEAVENWORTH
Mailing Address - State:KS
Mailing Address - Zip Code:66027-1208
Mailing Address - Country:US
Mailing Address - Phone:913-297-0193
Mailing Address - Fax:
Practice Address - Street 1:4101 S 4TH ST
Practice Address - Street 2:
Practice Address - City:LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66048-5014
Practice Address - Country:US
Practice Address - Phone:913-682-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-97827-091163W00000X, 163WC0400X, 163WE0003X, 163WG0000X, 163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered163W00000XNursing Service ProvidersRegistered Nurse
Not Answered163WC0400XNursing Service ProvidersRegistered NurseCase Management
Not Answered163WE0003XNursing Service ProvidersRegistered NurseEmergency
Not Answered163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Not Answered163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care