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:2025-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-97827-091163W00000X, 163WC0400X, 163WE0003X, 163WG0000X, 163WP2201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WE0003XNursing Service ProvidersRegistered NurseEmergency
No163W00000XNursing Service ProvidersRegistered Nurse
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No163WP2201XNursing Service ProvidersRegistered NurseAmbulatory Care