Provider Demographics
NPI: | 1639584535 |
---|---|
Name: | BROYLES, JENNIFER E (CRNA) |
Entity Type: | Individual |
Prefix: | |
First Name: | JENNIFER |
Middle Name: | E |
Last Name: | BROYLES |
Suffix: | |
Gender: | F |
Credentials: | CRNA |
Other - Prefix: | |
Other - First Name: | JENNIFER |
Other - Middle Name: | E |
Other - Last Name: | MAHAN |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | |
Mailing Address - Street 1: | 253 DOLARON LN |
Mailing Address - Street 2: | |
Mailing Address - City: | SOUTH CHARLESTON |
Mailing Address - State: | WV |
Mailing Address - Zip Code: | 25309-8109 |
Mailing Address - Country: | US |
Mailing Address - Phone: | |
Mailing Address - Fax: | |
Practice Address - Street 1: | 253 DOLARON LN |
Practice Address - Street 2: | |
Practice Address - City: | SOUTH CHARLESTON |
Practice Address - State: | WV |
Practice Address - Zip Code: | 25309-8109 |
Practice Address - Country: | US |
Practice Address - Phone: | 304-720-8816 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2014-06-30 |
Last Update Date: | 2021-12-23 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
WV | 93283 | 367500000X |
WV | 75505 | 367500000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 367500000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
WV | 9333201 | Other | GROUP MEDICARE |
WV | 0207026000 | Other | GROUP MEDICAID |
WV | 9333201 | Other | GROUP MEDICARE |
WV | 3810027789 | Medicaid |