Healthcare Provider Details

I. General information

NPI: 1235808213
Provider Name (Legal Business Name): DELESA R BROADNAX
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2021
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 METRO PL N STE 300
DUBLIN OH
43017-5320
US

IV. Provider business mailing address

525 METRO PL N STE 300
DUBLIN OH
43017-5320
US

V. Phone/Fax

Practice location:
  • Phone: 855-289-1722
  • Fax:
Mailing address:
  • Phone: 855-289-1722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberLPN.156549.MEDS-IV
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License NumberPN156549
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: