Provider Demographics
NPI:1265181556
Name:BROKENBERRY, GLORIA
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:
Last Name:BROKENBERRY
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 1
Mailing Address - Street 2:
Mailing Address - City:GLOSTER
Mailing Address - State:LA
Mailing Address - Zip Code:71030-0001
Mailing Address - Country:US
Mailing Address - Phone:318-461-9960
Mailing Address - Fax:
Practice Address - Street 1:1318 HIGHWAY 171
Practice Address - Street 2:
Practice Address - City:STONEWALL
Practice Address - State:LA
Practice Address - Zip Code:71078-9403
Practice Address - Country:US
Practice Address - Phone:318-906-5054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty