Healthcare Provider Details

I. General information

NPI: 1922437003
Provider Name (Legal Business Name): MRS. PATRICIA WATHEN BROADWAY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2013
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1326 11TH ST
SAINT CLOUD FL
34769-3709
US

IV. Provider business mailing address

1326 11TH ST
SAINT CLOUD FL
34769-3709
US

V. Phone/Fax

Practice location:
  • Phone: 407-892-9000
  • Fax: 407-892-9000
Mailing address:
  • Phone: 407-892-9000
  • Fax: 407-892-9000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberAS4944
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: