Healthcare Provider Details

I. General information

NPI: 1154896801
Provider Name (Legal Business Name): ANGELA MAE BROUGHTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/09/2018
Last Update Date: 10/09/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 GRASSLAND DR
MITCHELL SD
57301-6205
US

IV. Provider business mailing address

1900 GRASSLAND DR
MITCHELL SD
57301-6205
US

V. Phone/Fax

Practice location:
  • Phone: 605-995-7000
  • Fax:
Mailing address:
  • Phone: 605-995-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCP001468
License Number StateSD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: