Provider Demographics
NPI:1326525270
Name:BROUGHAL, KYLIE (PA)
Entity type:Individual
Prefix:
First Name:KYLIE
Middle Name:
Last Name:BROUGHAL
Suffix:
Gender:
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02907-2201
Mailing Address - Country:US
Mailing Address - Phone:401-648-4700
Mailing Address - Fax:
Practice Address - Street 1:7 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02907-2201
Practice Address - Country:US
Practice Address - Phone:401-648-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-24
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY022166363AM0700X
RIPA01436363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical