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General NPI Number Information
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NPI Number | 1578235453
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Entity Type | Individual
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Provider Name | BREANNA JORDAN BROUSSEAU NP
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Gender | Female
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Dates
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Enumeration Date | 09/29/2021
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Last Update Date | 02/03/2023
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Provider Practice Location Address
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Address Line | 1202 MEDICAL CENTER DR
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City | WILMINGTON
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State | NC
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Zip | 28401-7307
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Country | US
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Telephone | 910-341-3459
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Fax | 910-343-0438
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Provider Business Mailing Address
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Address Line | 1202 MEDICAL CENTER DR
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City | WILMINGTON
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State | NC
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Zip | 28401-7307
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Country | US
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Telephone | 910-617-6705
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Fax | 910-431-4048
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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 | 208VP0000X
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Taxonomy Name | Pain Medicine Physician
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License Number | 5015119
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 208VP0014X
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Taxonomy Name | Interventional Pain Medicine Physician
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License Number | 5015119
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License Number State | NC
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Taxonomy #3
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Taxonomy Code | 363L00000X
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Taxonomy Name | Nurse Practitioner
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License Number | 5015119
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License Number State | NC
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