Provider Demographics
NPI:1235259011
Name:BROYLES, JENNIFER S (MD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:S
Last Name:BROYLES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:SUE
Other - Last Name:HEAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6450 38TH AVE N STE 400
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33710-1653
Mailing Address - Country:US
Mailing Address - Phone:727-545-4444
Mailing Address - Fax:727-545-5855
Practice Address - Street 1:6450 38TH AVE N STE 400
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-1653
Practice Address - Country:US
Practice Address - Phone:727-545-4444
Practice Address - Fax:727-545-5855
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41052207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1508624Medicaid
TN30003921Medicare PIN
TN1508624Medicaid