Provider Demographics
NPI:1073700886
Name:BROXTON, IVEY (NP)
Entity Type:Individual
Prefix:MS
First Name:IVEY
Middle Name:
Last Name:BROXTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:IVEY
Other - Middle Name:ANDERSON
Other - Last Name:BROXTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN
Mailing Address - Street 1:1150 GOLDEN WAY
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-7712
Mailing Address - Country:US
Mailing Address - Phone:706-612-9401
Mailing Address - Fax:706-612-9420
Practice Address - Street 1:1150 GOLDEN WAY
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-7712
Practice Address - Country:US
Practice Address - Phone:706-612-9401
Practice Address - Fax:706-612-9420
Is Sole Proprietor?:No
Enumeration Date:2007-09-26
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN165181363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA524293389RMedicaid