Provider Demographics
NPI:1588979314
Name:BROUGHTON, CLYDENA JEAN (FNP - C)
Entity type:Individual
Prefix:
First Name:CLYDENA
Middle Name:JEAN
Last Name:BROUGHTON
Suffix:
Gender:F
Credentials:FNP - C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 HICKORY RD # 4
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314-1824
Mailing Address - Country:US
Mailing Address - Phone:304-752-1669
Mailing Address - Fax:
Practice Address - Street 1:4111 1ST AVE STE 3
Practice Address - Street 2:
Practice Address - City:NITRO
Practice Address - State:WV
Practice Address - Zip Code:25143-1345
Practice Address - Country:US
Practice Address - Phone:304-755-4797
Practice Address - Fax:304-755-4799
Is Sole Proprietor?:No
Enumeration Date:2010-08-17
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVAPRN62736-NP-C363LF0000X
VA0024183957363LF0000X
WV62736363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily