Provider Demographics
NPI:1013590637
Name:BROUGHTON, STACY ANN (REGISTERED NURSE)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:ANN
Last Name:BROUGHTON
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:W161N9517 BLACKFOOT DR
Mailing Address - Street 2:
Mailing Address - City:MENOMONEE FALLS
Mailing Address - State:WI
Mailing Address - Zip Code:53051-1565
Mailing Address - Country:US
Mailing Address - Phone:414-795-4257
Mailing Address - Fax:
Practice Address - Street 1:W161N9517 BLACKFOOT DR
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-1565
Practice Address - Country:US
Practice Address - Phone:414-795-4257
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-02
Last Update Date:2021-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI163175163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice