Provider Demographics
NPI:1467020529
Name:BROADWAY, KAYLA L (APRN)
Entity type:Individual
Prefix:
First Name:KAYLA
Middle Name:L
Last Name:BROADWAY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 839
Mailing Address - Street 2:
Mailing Address - City:WALNUT RIDGE
Mailing Address - State:AR
Mailing Address - Zip Code:72476-0839
Mailing Address - Country:US
Mailing Address - Phone:870-886-3211
Mailing Address - Fax:870-886-3616
Practice Address - Street 1:1309 W MAIN ST
Practice Address - Street 2:
Practice Address - City:WALNUT RIDGE
Practice Address - State:AR
Practice Address - Zip Code:72476-1430
Practice Address - Country:US
Practice Address - Phone:870-886-3211
Practice Address - Fax:870-886-3616
Is Sole Proprietor?:No
Enumeration Date:2021-06-15
Last Update Date:2024-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR216315363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR216315OtherLICENSE