Provider Demographics
NPI:1376376236
Name:BROYLES, LISA ANN (FNP)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:BROYLES
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47330-9676
Mailing Address - Country:US
Mailing Address - Phone:765-855-3424
Mailing Address - Fax:
Practice Address - Street 1:705 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:IN
Practice Address - Zip Code:47330-9676
Practice Address - Country:US
Practice Address - Phone:765-855-3424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-24
Last Update Date:2024-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28133360A364SL0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SL0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistLong-Term Care