Provider Demographics
NPI:1215944855
Name:BROUGHMAN, KENICE ANNE (DC)
Entity type:Individual
Prefix:DR
First Name:KENICE
Middle Name:ANNE
Last Name:BROUGHMAN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:KENICE
Other - Middle Name:ANNE
Other - Last Name:GRAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:4555 N LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-2102
Mailing Address - Country:US
Mailing Address - Phone:773-328-8153
Mailing Address - Fax:
Practice Address - Street 1:4555 N LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-2102
Practice Address - Country:US
Practice Address - Phone:386-763-2763
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0006374111NN1001X
IL038.005796111NN1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NN1001XChiropractic ProvidersChiropractorNutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000872000Medicaid
FL000872000Medicaid