Provider Demographics
NPI:1487324844
Name:BROUGHTON, EDITH (RN)
Entity type:Individual
Prefix:MS
First Name:EDITH
Middle Name:
Last Name:BROUGHTON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13629 ERIN DR
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92555-2524
Mailing Address - Country:US
Mailing Address - Phone:951-337-7860
Mailing Address - Fax:
Practice Address - Street 1:13629 ERIN DR
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-2524
Practice Address - Country:US
Practice Address - Phone:951-337-7860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-16
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA409365163WG0000X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WG0000XNursing Service ProvidersRegistered NurseGeneral PracticeGroup - Single Specialty