Healthcare Provider Details

I. General information

NPI: 1578523718
Provider Name (Legal Business Name): KIM P. BROUSSARD CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 S COLLEGE RD SUITE 100
LAFAYETTE LA
70503-3038
US

IV. Provider business mailing address

PO BOX 1447
ABBEVILLE LA
70511-1447
US

V. Phone/Fax

Practice location:
  • Phone: 337-233-8603
  • Fax:
Mailing address:
  • Phone: 337-898-2803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN037148/AP02026
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: