Provider Demographics
NPI:1902950868
Name:BROAD, S DIANNE (CRNP)
Entity type:Individual
Prefix:MRS
First Name:S
Middle Name:DIANNE
Last Name:BROAD
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:MISS
Other - First Name:S
Other - Middle Name:DIANNE
Other - Last Name:DAWSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1 MORROW WAY
Mailing Address - Street 2:MCLACHLAN STUDENT HEALTH CENTER
Mailing Address - City:SLIPPERY ROCK
Mailing Address - State:PA
Mailing Address - Zip Code:16057-1326
Mailing Address - Country:US
Mailing Address - Phone:724-738-2052
Mailing Address - Fax:724-738-2078
Practice Address - Street 1:1 MORROW WAY
Practice Address - Street 2:MCLACHLAN STUDENT HEALTH CENTER
Practice Address - City:SLIPPERY ROCK
Practice Address - State:PA
Practice Address - Zip Code:16057-1326
Practice Address - Country:US
Practice Address - Phone:724-738-2052
Practice Address - Fax:724-738-2078
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAUP001335K363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health