Provider Demographics
NPI:1831401314
Name:BROUGHTON, BETTINA L (NP)
Entity type:Individual
Prefix:MRS
First Name:BETTINA
Middle Name:L
Last Name:BROUGHTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 CULVER RD
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14609-1716
Mailing Address - Country:US
Mailing Address - Phone:585-336-5320
Mailing Address - Fax:585-697-1598
Practice Address - Street 1:2615 CULVER RD
Practice Address - Street 2:100
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14609-1716
Practice Address - Country:US
Practice Address - Phone:585-336-5320
Practice Address - Fax:585-697-1598
Is Sole Proprietor?:No
Enumeration Date:2010-07-13
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF430512-1363L00000X
NY430512363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03271890Medicaid
NY03271890Medicaid
NYJ400086094Medicare PIN