Healthcare Provider Details

I. General information

NPI: 1174632954
Provider Name (Legal Business Name): LAURA BROUSSARD APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA FORBES

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 06/19/2020
Certification Date: 06/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 CAMELIA ST
ROYAL CITY WA
99357
US

IV. Provider business mailing address

820 N CHELAN AVE
WENATCHEE WA
98801-2028
US

V. Phone/Fax

Practice location:
  • Phone: 509-663-8711
  • Fax:
Mailing address:
  • Phone: 509-663-8711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP61075750
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: