Healthcare Provider Details

I. General information

NPI: 1649107988
Provider Name (Legal Business Name): MARIE ROUSSAW NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2026
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

483 INDIAN TRAIL LILBURN RD NW
LILBURN GA
30047-3717
US

IV. Provider business mailing address

820 GATESHEAD LN
LAWRENCEVILLE GA
30043-6668
US

V. Phone/Fax

Practice location:
  • Phone: 770-923-4433
  • Fax:
Mailing address:
  • Phone: 302-559-4588
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN-NP242283
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: