=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689551053
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELLE D BROUSSARD PHD, RDN, LD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2025
-----------------------------------------------------
Last Update Date | 08/18/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4300 WARD BLUFF DR
-----------------------------------------------------
City | ELLENWOOD
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30294-1783
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-216-2067
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4300 WARD BLUFF DR
-----------------------------------------------------
City | ELLENWOOD
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30294-1783
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 404-216-2067
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133NN1002X
-----------------------------------------------------
Taxonomy Name | Nutrition Education Nutritionist
-----------------------------------------------------
License Number | LD002261
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 132700000X
-----------------------------------------------------
Taxonomy Name | Dietary Manager
-----------------------------------------------------
License Number | LD002261
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 133VN1005X
-----------------------------------------------------
Taxonomy Name | Renal Nutrition Registered Dietitian
-----------------------------------------------------
License Number | LD00261
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 261QC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Clinic/Center
-----------------------------------------------------
License Number | LD002261
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | LD002261
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------