Provider Demographics
NPI:1477871317
Name:BROYLES, DEWLENE (RNC,IBCLC)
Entity Type:Individual
Prefix:
First Name:DEWLENE
Middle Name:
Last Name:BROYLES
Suffix:
Gender:F
Credentials:RNC,IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 RAMBLING TRL
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76087-6892
Mailing Address - Country:US
Mailing Address - Phone:817-821-6970
Mailing Address - Fax:
Practice Address - Street 1:107 RAMBLING TRL
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76087-6892
Practice Address - Country:US
Practice Address - Phone:817-821-6970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-15
Last Update Date:2012-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX222758163WM0102X
TX197-13815163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX2826661Medicaid