Provider Demographics
NPI:1053540674
Name:BROUGHTON, MICHELLE LOUISE (APRN)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LOUISE
Last Name:BROUGHTON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1325
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40702-1325
Mailing Address - Country:US
Mailing Address - Phone:606-526-8131
Mailing Address - Fax:606-528-8661
Practice Address - Street 1:602 KNOX ST
Practice Address - Street 2:
Practice Address - City:BARBOURVILLE
Practice Address - State:KY
Practice Address - Zip Code:40906-1304
Practice Address - Country:US
Practice Address - Phone:606-546-6027
Practice Address - Fax:606-546-2084
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-02
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006067363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100100740Medicaid
KYP01432838OtherRR MCR
KYP01432838OtherRR MCR
KY6067POtherARNP LICENSE