Healthcare Provider Details

I. General information

NPI: 1245743509
Provider Name (Legal Business Name): DESTINY BROADEN AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2017
Last Update Date: 01/18/2021
Certification Date: 01/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

98 E LAKE MEAD PKWY STE 105
HENDERSON NV
89015-6443
US

IV. Provider business mailing address

5815 NUEVO LEON ST UNIT 7
NORTH LAS VEGAS NV
89031-4100
US

V. Phone/Fax

Practice location:
  • Phone: 702-861-1183
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberA2181
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: