Healthcare Provider Details

I. General information

NPI: 1700743101
Provider Name (Legal Business Name): TRACIE ROUSSEL O'BANNON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/07/2026
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

735 HIGHWAY 30 STE D
SAINT GABRIEL LA
70776-5015
US

IV. Provider business mailing address

39041 BALMORAL DR
PRAIRIEVILLE LA
70769-4854
US

V. Phone/Fax

Practice location:
  • Phone: 225-314-9314
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number245084
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: