MEDICARE: MARIE ROUSSAW NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	APRN-NP242283	GA

General Provider Information

NPI Number	:	1649107988
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIE ROUSSAW NP

Provider Business Mailing Address
First Line	:	820 GATESHEAD LN
Second Line	:
City	:	LAWRENCEVILLE
State	:	GA
Zip	:	30043-6668
Country	:	US
Telephone Number	:	302-559-4588
Fax Number	:

Provider Business Practice Location Address
First Line	:	483 INDIAN TRAIL LILBURN RD NW
Second Line	:
City	:	LILBURN
State	:	GA
Zip	:	30047-3717
Country	:	US
Telephone Number	:	770-923-4433
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/08/2026
Last Update Date	:	05/08/2026

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