Provider Demographics
NPI:1457302739
Name:BROYLES, DIANA S (CRNA)
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:S
Last Name:BROYLES
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:DIANA
Other - Middle Name:S
Other - Last Name:BANKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 10824
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35202-0824
Mailing Address - Country:US
Mailing Address - Phone:205-322-1808
Mailing Address - Fax:205-322-1851
Practice Address - Street 1:1000 W MORENO ST
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32501-2316
Practice Address - Country:US
Practice Address - Phone:850-437-8390
Practice Address - Fax:850-437-8394
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2040502367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL59170251OtherBLUE SHIELD
FLG2613OtherBLUE SHIELD
AL59170250OtherBLUE SHIELD
P00148698OtherPALMETTO GBA - RR MEDICAR
FLG2613OtherBLUE SHIELD
AL59170251OtherBLUE SHIELD