Healthcare Provider Details

I. General information

NPI: 1437151636
Provider Name (Legal Business Name): ROMONA BROUSSARD MAYEUX FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 01/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

248 E CAPITOL ST ROOM 105
JACKSON MS
39201-2503
US

IV. Provider business mailing address

248 E CAPITOL ST ROOM 105
JACKSON MS
39201-2503
US

V. Phone/Fax

Practice location:
  • Phone: 601-714-2563
  • Fax: 601-510-4653
Mailing address:
  • Phone: 601-714-2563
  • Fax: 601-510-4653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN041380 AP01824
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR881289
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: