1265916936 NPI number — MRS. CANDIA MARIE BROUGHTON APRN, FNP-C

Table of content: MRS. CANDIA MARIE BROUGHTON APRN, FNP-C (NPI 1265916936)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265916936 NPI number — MRS. CANDIA MARIE BROUGHTON APRN, FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROUGHTON
Provider First Name:
CANDIA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APRN, FNP-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1265916936
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 909
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40201-0909
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-974-3447
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4200 LAWRENCEBURG RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRANKFORT
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40601-8936
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
502-227-4821
Provider Business Practice Location Address Fax Number:
502-227-3013
Provider Enumeration Date:
09/19/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  3012693 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1084003 . This is a "RN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 3012693 . This is a "APRN" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".




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