Provider Demographics
NPI:1902202641
Name:BROUGHTON, TONYA M (APRN, FNP-BC)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:M
Last Name:BROUGHTON
Suffix:
Gender:F
Credentials:APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1454 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47111-1839
Mailing Address - Country:US
Mailing Address - Phone:812-503-5071
Mailing Address - Fax:812-503-5076
Practice Address - Street 1:1454 MARKET ST
Practice Address - Street 2:
Practice Address - City:CHARLESTOWN
Practice Address - State:IN
Practice Address - Zip Code:47111-1839
Practice Address - Country:US
Practice Address - Phone:812-503-5071
Practice Address - Fax:812-503-5076
Is Sole Proprietor?:No
Enumeration Date:2014-11-07
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71005212A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201267300Medicaid
INDN0930OtherRAILROAD MEDICARE
IN000000904699OtherANTHEM
INDN0930OtherRAILROAD MEDICARE