MEDICARE: JEANETTA MARIE BROADWAY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172A00000X	Driver

General Provider Information

NPI Number	:	1295136224
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEANETTA MARIE BROADWAY

Provider Business Mailing Address
First Line	:	4014 AUTUMN SPRINGS CV
Second Line	:	NONE
City	:	MEMPHIS
State	:	TN
Zip	:	38125-2647
Country	:	US
Telephone Number	:	901-279-5289
Fax Number	:

Provider Business Practice Location Address
First Line	:	4014 AUTUMN SPRINGS CV
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38125-2647
Country	:	US
Telephone Number	:	901-279-5289
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/09/2014
Last Update Date	:	09/09/2014

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Directions to “ JEANETTA MARIE BROADWAY ” Practice Location

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