Healthcare Provider Details

I. General information

NPI: 1376376236
Provider Name (Legal Business Name): LISA ANN BROYLES FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2024
Last Update Date: 08/24/2024
Certification Date: 08/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 E MAIN ST
CENTERVILLE IN
47330-9676
US

IV. Provider business mailing address

705 E MAIN ST
CENTERVILLE IN
47330-9676
US

V. Phone/Fax

Practice location:
  • Phone: 765-855-3424
  • Fax:
Mailing address:
  • Phone: 765-855-3424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SL0600X
TaxonomyLong-Term Care Clinical Nurse Specialist
License Number28133360A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: