MEDICARE: BROUSSARD FAMILY PRACTICE, PLLC

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	651610	TX
2	174400000X	Specialist	L2891	TX

General Provider Information

NPI Number	:	1710320908
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BROUSSARD FAMILY PRACTICE, PLLC

Provider Business Mailing Address
First Line	:	PO BOX 7096
Second Line	:
City	:	BEAUMONT
State	:	TX
Zip	:	77726-7096
Country	:	US
Telephone Number	:	409-833-0342
Fax Number	:	877-770-4091

Provider Business Practice Location Address
First Line	:	810 HOSPITAL DR STE 100
Second Line	:
City	:	BEAUMONT
State	:	TX
Zip	:	77701-4633
Country	:	US
Telephone Number	:	409-833-0342
Fax Number	:

Authorized Official
Title or Position	:	FAMILY NURSE PRACTITIONER/OWNER
Name	:	MRS. JULIETTE ROSE BROUSSARD
Credential	:	FNPC
Telephone Number	:	409-833-0342

Provider Enumeration Date	:	04/08/2013
Last Update Date	:	07/21/2022

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