=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922965573
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KAILEA ANNE BRORMAN FNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2026
-----------------------------------------------------
Last Update Date | 01/06/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 130 JIMMA DR UNIT A
-----------------------------------------------------
City | WILLOW PARK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76087-1331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-363-1400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 130 JIMMA DR UNIT A
-----------------------------------------------------
City | WILLOW PARK
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76087-1331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-363-1400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RG0100X
-----------------------------------------------------
Taxonomy Name | Gastroenterology Physician
-----------------------------------------------------
License Number | 1208621
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------