Healthcare Provider Details

I. General information

NPI: 1538561048
Provider Name (Legal Business Name): KELLY BROUSSARD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2014
Last Update Date: 02/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 LINDBERG DR
SLIDELL LA
70458-8062
US

IV. Provider business mailing address

4664 PAINTERS ST
NEW ORLEANS LA
70122-5002
US

V. Phone/Fax

Practice location:
  • Phone: 985-649-4063
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number07870
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: