Healthcare Provider Details

I. General information

NPI: 1184122145
Provider Name (Legal Business Name): JAMILIA LASHAWN BROUSSARD MSN RN FNP-BC WCC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2018
Last Update Date: 08/03/2021
Certification Date: 08/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 12TH AVE NW
ARDMORE OK
73401-5712
US

IV. Provider business mailing address

PO BOX 678219
DALLAS TX
75267-8219
US

V. Phone/Fax

Practice location:
  • Phone: 580-220-6290
  • Fax: 580-220-6215
Mailing address:
  • Phone: 214-970-6817
  • Fax: 844-803-4513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number821209
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP136689
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: