Basic Information
| Provider Information | |||||||||
| NPI: | 1881215424 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROUGHTON | ||||||||
| FirstName: | SAMANTHA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1034 SHERBROOKE RD | ||||||||
| Address2: | |||||||||
| City: | SAINT CHARLES | ||||||||
| State: | MO | ||||||||
| PostalCode: | 633034027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142671363 | ||||||||
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| Practice Location | |||||||||
| Address1: | 10010 KENNERLY RD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631282106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3145251000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2020 | ||||||||
| LastUpdateDate: | 05/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 2020011684 | MO | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.