Provider Demographics
NPI:1366097362
Name:BROUGHTON, ANN-TOY ELLSWORTH
Entity type:Individual
Prefix:
First Name:ANN-TOY
Middle Name:ELLSWORTH
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 1:10570 RAMMELL MOUNTAIN RD
Mailing Address - Street 2:
Mailing Address - City:TETONIA
Mailing Address - State:ID
Mailing Address - Zip Code:83452-4971
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10570 RAMMELL MOUNTAIN RD
Practice Address - Street 2:
Practice Address - City:TETONIA
Practice Address - State:ID
Practice Address - Zip Code:83452-4971
Practice Address - Country:US
Practice Address - Phone:208-456-2758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-06
Last Update Date:2019-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider