1326172990 NPI number — JENNIFER ELIZABETH BROUGHTON COTAL

Table of content: JENNIFER ELIZABETH BROUGHTON COTAL (NPI 1326172990)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326172990 NPI number — JENNIFER ELIZABETH BROUGHTON COTAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROUGHTON
Provider First Name:
JENNIFER
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
COTAL
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STARON
Provider Other First Name:
JENNIFER
Provider Other Middle Name:
ELIZABETH
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
COTAL
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1326172990
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
327 NAUVOO RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORRIS
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
16938-9568
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
570-353-2718
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 SHERMAN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WELLSBORO
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16901-1829
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
570-724-1811
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/15/2007

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: 224Z00000X , with the licence number:  OP003316L , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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