Healthcare Provider Details

I. General information

NPI: 1770748097
Provider Name (Legal Business Name): KENEITRA BROWN ROUSSELL PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2008
Last Update Date: 05/21/2025
Certification Date: 05/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3584 W AIRLINE HWY
RESERVE LA
70084-5708
US

IV. Provider business mailing address

3584 W AIRLINE HWY
RESERVE LA
70084-5708
US

V. Phone/Fax

Practice location:
  • Phone: 985-200-3836
  • Fax:
Mailing address:
  • Phone: 985-200-3836
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberPA200279
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: