Provider Demographics
NPI:1447964499
Name:BROADNAX, TERI (LDN, CNS)
Entity type:Individual
Prefix:
First Name:TERI
Middle Name:
Last Name:BROADNAX
Suffix:
Gender:F
Credentials:LDN, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:PARK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60466-1753
Mailing Address - Country:US
Mailing Address - Phone:630-890-3081
Mailing Address - Fax:
Practice Address - Street 1:20 FOREST BLVD
Practice Address - Street 2:
Practice Address - City:PARK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60466-1753
Practice Address - Country:US
Practice Address - Phone:630-890-3081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-12
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist