Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP0808X | Nurse Practitioner - Psychiatric/Mental Health | 0024181570 | VA |
NPI | 1003383688 |
---|---|
Provider Name | Latricia Broaddus |
First Address | Mechanicsville, VA 23116-3845 |
Second Address | Mechanicsville, VA 23116-3845 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 31/10/2018 |
Last Update Date | 07/01/2022 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0732762767 | (05) | VA |