Provider Demographics
NPI:1174737522
Name:BROADWELL, PRUDENCE ARMANDINE (LAC)
Entity type:Individual
Prefix:DR
First Name:PRUDENCE
Middle Name:ARMANDINE
Last Name:BROADWELL
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:18837 BROOKHURST ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708
Mailing Address - Country:US
Mailing Address - Phone:714-965-9266
Mailing Address - Fax:714-965-9268
Practice Address - Street 1:18837 BROOKHURST ST
Practice Address - Street 2:SUITE 210
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708
Practice Address - Country:US
Practice Address - Phone:714-965-9266
Practice Address - Fax:714-965-9268
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC3178171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist