Healthcare Provider Details

I. General information

NPI: 1730549163
Provider Name (Legal Business Name): DOROTHY M BROADWAY CNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2016
Last Update Date: 03/14/2025
Certification Date:
Deactivation Date: 03/29/2019
Reactivation Date: 03/14/2025

III. Provider practice location address

130 S 16TH ST
WEST MEMPHIS AR
72301-4610
US

IV. Provider business mailing address

130 S 16TH ST
WEST MEMPHIS AR
72301-4610
US

V. Phone/Fax

Practice location:
  • Phone: 870-732-7981
  • Fax: 870-732-7984
Mailing address:
  • Phone: 870-732-7981
  • Fax: 870-732-7984

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number208584752
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: