Provider Demographics
NPI:1962847822
Name:BROUGHTON, STACI
Entity Type:Individual
Prefix:
First Name:STACI
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:PO BOX 618
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-0618
Mailing Address - Country:US
Mailing Address - Phone:469-426-8683
Mailing Address - Fax:
Practice Address - Street 1:5101 N 34TH ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74014-1710
Practice Address - Country:US
Practice Address - Phone:918-605-6796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-06
Last Update Date:2013-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK117099246ZS0410X
OK145868246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist