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General NPI Number Information
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NPI Number | 1871036194
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Entity Type | Organization
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Legal Business Name | U.S. AIR FORCE
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Dates
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Enumeration Date | 11/19/2016
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Last Update Date | 11/19/2016
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Provider Practice Location Address
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Address Line | 2323 JULIAN LN
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City | FAIRFIELD
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State | CA
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Zip | 94534-3131
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Country | US
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Telephone | 301-633-9503
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Fax |
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Provider Business Mailing Address
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Address Line | 2323 JULIAN LN
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City | FAIRFIELD
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State | CA
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Zip | 94534-3131
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Country | US
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Telephone | 301-633-9503
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Fax |
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Authorized Official
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Title or Position | PMHNP
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Name | DR. RACHEL ANNE BROUSSARD
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Credential | DNP
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Telephone | 301-633-9503
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number | R190890
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License Number State | MD
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