Healthcare Provider Details

I. General information

NPI: 1124601026
Provider Name (Legal Business Name): SHELLEY BROUSSARD RN,BSN,IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SHELLEY JONES

II. Dates (important events)

Enumeration Date: 04/29/2021
Last Update Date: 04/29/2021
Certification Date: 04/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4630 AMBASSADOR CAFFERY PKWY STE 204
LAFAYETTE LA
70508-6949
US

IV. Provider business mailing address

4704 AMBASSADOR CAFFERY PKWY FL PAKWAY2
LAFAYETTE LA
70508-6908
US

V. Phone/Fax

Practice location:
  • Phone: 337-470-5546
  • Fax:
Mailing address:
  • Phone: 337-470-5594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number48443
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: