Basic Information
| Provider Information | |||||||||
| NPI: | 1619970308 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROUSSARD | ||||||||
| FirstName: | TRACY | ||||||||
| MiddleName: | P | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | F.N.P. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 52028 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705052028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3373540030 | ||||||||
| FaxNumber: | 3373540026 | ||||||||
| Practice Location | |||||||||
| Address1: | 155 HOSPITAL DR | ||||||||
| Address2: | STE 100 | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705032852 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3373540030 | ||||||||
| FaxNumber: | 3373540026 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2005 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | X | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | RN087132 AP04548 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.