Provider Demographics
NPI:1932946548
Name:BROADEN, TERENCIA
Entity type:Individual
Prefix:
First Name:TERENCIA
Middle Name:
Last Name:BROADEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 MOORE DR
Mailing Address - Street 2:
Mailing Address - City:CECIL
Mailing Address - State:AL
Mailing Address - Zip Code:36013-3003
Mailing Address - Country:US
Mailing Address - Phone:334-328-2330
Mailing Address - Fax:
Practice Address - Street 1:12222 MERIT DR STE 600
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75251-3294
Practice Address - Country:US
Practice Address - Phone:972-715-5000
Practice Address - Fax:972-715-9976
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-10
Last Update Date:2024-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-157348367500000X, 163W00000X
TX1176796367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse