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NPI Code Detail

MEDICARE: MARY JO BROUSSARD

MEDICARE: MARY JO BROUSSARD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363L00000XNurse Practitioner046359-3340LA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1046359-3340OTHERLASTATE BOARD NURSING

General Provider Information

NPI Number : 1285844571
Entity Type Code : Individual
Provider Name (Legal Business Name) : MARY JO BROUSSARD
Provider Business Mailing Address
First Line : 1541 TULANE AVE
Second Line :
City : NEW ORLEANS
State : LA
Zip : 70112-2821
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 1541 TULANE AVE
Second Line :
City : NEW ORLEANS
State : LA
Zip : 70112-2821
Country : US
Telephone Number : 504-903-1301
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/23/2007
Last Update Date : 07/08/2007

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