Provider Demographics
NPI:1649775198
Name:BROYLES, CASSIE (CNP,-FNP)
Entity Type:Individual
Prefix:
First Name:CASSIE
Middle Name:
Last Name:BROYLES
Suffix:
Gender:F
Credentials:CNP,-FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9941 GRABILL RD
Mailing Address - Street 2:
Mailing Address - City:NEW VIENNA
Mailing Address - State:OH
Mailing Address - Zip Code:45159-9620
Mailing Address - Country:US
Mailing Address - Phone:937-402-1174
Mailing Address - Fax:
Practice Address - Street 1:325 REGENCY RIDGE DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-4252
Practice Address - Country:US
Practice Address - Phone:937-436-3833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.022463363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHAPRN.CNP.022463Medicaid