Healthcare Provider Details

I. General information

NPI: 1962628156
Provider Name (Legal Business Name): BRENDA A BROUSSARD RD, CDE, BC-ADM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PRESBYTERIAN FAMILY PRACTICE MEDICAL GROUP 3901 ATRISCO
ALBUQUERQUE NM
87120
US

IV. Provider business mailing address

18 BERM ST NW
ALBUQUERQUE NM
87120-1822
US

V. Phone/Fax

Practice location:
  • Phone: 505-462-7575
  • Fax:
Mailing address:
  • Phone: 505-792-0065
  • Fax: 505-792-0488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number036
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: