Provider Demographics
NPI:1992427033
Name:BROUGHTON, MARANDA
Entity type:Individual
Prefix:
First Name:MARANDA
Middle Name:
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 1:3146 PANTHER TRL SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30311-5426
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3146 PANTHER TRL SW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30311-5426
Practice Address - Country:US
Practice Address - Phone:404-621-7166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-15
Last Update Date:2022-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility