Provider Demographics
NPI:1255141834
Name:BROUGHTON, REYFANETTE
Entity type:Individual
Prefix:MRS
First Name:REYFANETTE
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 1:128 S EAST ST UNIT 555
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-4030
Mailing Address - Country:US
Mailing Address - Phone:219-424-2888
Mailing Address - Fax:
Practice Address - Street 1:2505 HARVEST DR
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-9679
Practice Address - Country:US
Practice Address - Phone:219-424-2888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-07
Last Update Date:2025-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier