Healthcare Provider Details

I. General information

NPI: 1053615773
Provider Name (Legal Business Name): LUZ MARIA BROUSSEAU LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MISS LUZ MARIA ESPINOZA MUNIZ

II. Dates (important events)

Enumeration Date: 01/10/2011
Last Update Date: 04/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 NE 8TH ST STE 300
GRESHAM OR
97030-7318
US

IV. Provider business mailing address

600 NE 8TH ST STE 300
GRESHAM OR
97030-7318
US

V. Phone/Fax

Practice location:
  • Phone: 503-988-8500
  • Fax:
Mailing address:
  • Phone: 503-988-8500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number201030226
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: