Basic Information
| Provider Information | |||||||||
| NPI: | 1851597504 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROUSSARD | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | NNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6431 FANNIN ST STE 3.242 | ||||||||
| Address2: | |||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770301501 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7135003500 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6410 FANNIN ST | ||||||||
| Address2: | 500 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770303000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8323257111 | ||||||||
| FaxNumber: | 7135122227 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2007 | ||||||||
| LastUpdateDate: | 02/10/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LN0000X | 670437 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal |
ID Information
| ID | Type | State | Issuer | Description | 8Y3004 | 01 | TX | BCBS | OTHER | 189514601 | 05 | TX | MEDICAID | 189514602 | 01 | TX | CSHCN | OTHER |