Provider Demographics
NPI:1053843722
Name:BROOMER, KAYWANA LEE
Entity Type:Individual
Prefix:
First Name:KAYWANA
Middle Name:LEE
Last Name:BROOMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 E NEWPORT PIKE
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19804-1921
Mailing Address - Country:US
Mailing Address - Phone:302-250-3101
Mailing Address - Fax:
Practice Address - Street 1:1007 E NEWPORT PIKE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19804-1921
Practice Address - Country:US
Practice Address - Phone:302-250-3101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-31
Last Update Date:2017-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPC009250101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health