MEDICARE: DIANA MARIE BROADWAY APRN-CNP

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	363LF0000X	Family Nurse Practitioner	216506	AR
2	363LF0000X	Family Nurse Practitioner	25919	SC

General Provider Information

NPI Number	:	1265002554
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANA MARIE BROADWAY APRN-CNP

Provider Business Mailing Address
First Line	:	9313 MEDICAL PLAZA DR STE 202
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29406-9176
Country	:	US
Telephone Number	:	843-572-1200
Fax Number	:

Provider Business Practice Location Address
First Line	:	9313 MEDICAL PLAZA DR STE 202
Second Line	:
City	:	CHARLESTON
State	:	SC
Zip	:	29406-9176
Country	:	US
Telephone Number	:	843-572-1200
Fax Number	:	843-553-0424

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

Provider Enumeration Date	:	06/29/2021
Last Update Date	:	05/19/2022

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