MEDICARE: TRACIE ROUSSEL O'BANNON

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	363LF0000X	Family Nurse Practitioner	245084	LA

General Provider Information

NPI Number	:	1700743101
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACIE ROUSSEL O'BANNON

Provider Business Mailing Address
First Line	:	39041 BALMORAL DR
Second Line	:
City	:	PRAIRIEVILLE
State	:	LA
Zip	:	70769-4854
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	39041 BALMORAL DR
Second Line	:
City	:	PRAIRIEVILLE
State	:	LA
Zip	:	70769-4854
Country	:	US
Telephone Number	:	225-450-4234
Fax Number	:

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

Provider Enumeration Date	:	01/07/2026
Last Update Date	:	01/07/2026

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Directions to “ TRACIE ROUSSEL O'BANNON ” Practice Location

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