Provider Demographics
NPI:1609057454
Name:BROUGHTON, MARIA ANNE
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:ANNE
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 1:211 BLANCHARD AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:AR
Mailing Address - Zip Code:72560
Mailing Address - Country:US
Mailing Address - Phone:866-533-1759
Mailing Address - Fax:870-269-2196
Practice Address - Street 1:211 BLANCHARD AVE
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:AR
Practice Address - Zip Code:72560
Practice Address - Country:US
Practice Address - Phone:866-533-1759
Practice Address - Fax:870-269-2196
Is Sole Proprietor?:No
Enumeration Date:2007-11-21
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1609057454Medicaid