1902950868 NPI number — MRS. S DIANNE BROAD CRNP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902950868 NPI number — MRS. S DIANNE BROAD CRNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROAD
Provider First Name:
S
Provider Middle Name:
DIANNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CRNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DAWSON
Provider Other First Name:
S
Provider Other Middle Name:
DIANNE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1902950868
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1 MORROW WAY
Provider Second Line Business Mailing Address:
MCLACHLAN STUDENT HEALTH CENTER
Provider Business Mailing Address City Name:
SLIPPERY ROCK
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16057-1326
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-738-2052
Provider Business Mailing Address Fax Number:
724-738-2078

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 MORROW WAY
Provider Second Line Business Practice Location Address:
MCLACHLAN STUDENT HEALTH CENTER
Provider Business Practice Location Address City Name:
SLIPPERY ROCK
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16057-1326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-738-2052
Provider Business Practice Location Address Fax Number:
724-738-2078
Provider Enumeration Date:
01/22/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  UP001335K , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)