Provider Demographics
NPI:1639584535
Name:BROYLES, JENNIFER E (CRNA)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:E
Last Name:BROYLES
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:E
Other - Last Name:MAHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:253 DOLARON LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-8109
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:253 DOLARON LN
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-8109
Practice Address - Country:US
Practice Address - Phone:304-720-8816
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-30
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV93283367500000X
WV75505367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9333201OtherGROUP MEDICARE
WV0207026000OtherGROUP MEDICAID
WV9333201OtherGROUP MEDICARE
WV3810027789Medicaid