Provider Demographics
NPI:1942175120
Name:BRAUMAN, KYLE
Entity type:Individual
Prefix:
First Name:KYLE
Middle Name:
Last Name:BRAUMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:404 W PINE ST
Mailing Address - Street 2:
Mailing Address - City:FAIRBURY
Mailing Address - State:IL
Mailing Address - Zip Code:61739-1449
Mailing Address - Country:US
Mailing Address - Phone:815-419-7597
Mailing Address - Fax:
Practice Address - Street 1:404 W PINE ST
Practice Address - Street 2:
Practice Address - City:FAIRBURY
Practice Address - State:IL
Practice Address - Zip Code:61739-1449
Practice Address - Country:US
Practice Address - Phone:815-419-7597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-10-08
Last Update Date:2025-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered