Healthcare Provider Details

I. General information

NPI: 1770998437
Provider Name (Legal Business Name): AMY L BROUSSARD CST, CSFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2014
Last Update Date: 06/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1117 EIGHTH ST
LAKE ARTHUR LA
70549-3401
US

IV. Provider business mailing address

PO BOX 396
LAKE ARTHUR LA
70549-0396
US

V. Phone/Fax

Practice location:
  • Phone: 337-501-9813
  • Fax:
Mailing address:
  • Phone: 337-501-9813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: