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General NPI Number Information
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NPI Number | 1265034516
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Entity Type | Individual
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Provider Name | SHANIKA BROUSSARD
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Gender | Female
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Dates
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Enumeration Date | 11/11/2020
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Last Update Date | 11/11/2020
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Provider Practice Location Address
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Address Line | 6163 E LAMAR ST
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City | BAY SAINT LOUIS
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State | MS
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Zip | 39520-8267
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Country | US
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Telephone | 504-908-5893
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Fax |
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Provider Business Mailing Address
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Address Line | 1110 COWAN RD. SUITE B #2014
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City | GULFPORT
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State | MS
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Zip | 39507
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Country | US
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Telephone | 228-254-3037
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Fax | 228-335-6029
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 372600000X
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Taxonomy Name | Adult Companion
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License Number |
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License Number State | MS
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