Provider Demographics
NPI:1356632996
Name:BROUGHTON, GWENDOLYN
Entity Type:Individual
Prefix:MRS
First Name:GWENDOLYN
Middle Name:
Last Name:BROUGHTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1867 S CROSS ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72206-1056
Mailing Address - Country:US
Mailing Address - Phone:501-554-3157
Mailing Address - Fax:
Practice Address - Street 1:5800 W 10TH ST
Practice Address - Street 2:101
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72204-1752
Practice Address - Country:US
Practice Address - Phone:501-660-6886
Practice Address - Fax:501-660-6838
Is Sole Proprietor?:No
Enumeration Date:2011-05-01
Last Update Date:2011-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARL14757164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARL14757OtherLPN