Provider Demographics
NPI:1528349230
Name:BROADWAY, SUZANNE LOUISE (RNP)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:LOUISE
Last Name:BROADWAY
Suffix:
Gender:F
Credentials:RNP
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:LOUISE
Other - Last Name:WREN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RNP
Mailing Address - Street 1:9500 LILE DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-6319
Mailing Address - Country:US
Mailing Address - Phone:501-219-8777
Mailing Address - Fax:501-219-8333
Practice Address - Street 1:9500 LILE DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-6319
Practice Address - Country:US
Practice Address - Phone:501-219-8777
Practice Address - Fax:501-219-8333
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP00745363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5X184Medicare PIN