Healthcare Provider Details

I. General information

NPI: 1578235453
Provider Name (Legal Business Name): BREANNA JORDAN BROUSSEAU NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2021
Last Update Date: 02/03/2023
Certification Date: 02/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 MEDICAL CENTER DR
WILMINGTON NC
28401-7307
US

IV. Provider business mailing address

1202 MEDICAL CENTER DR
WILMINGTON NC
28401-7307
US

V. Phone/Fax

Practice location:
  • Phone: 910-341-3459
  • Fax: 910-343-0438
Mailing address:
  • Phone: 910-617-6705
  • Fax: 910-431-4048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number5015119
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number5015119
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5015119
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: