Individual
KELLY BROUSSARD
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
1700 LINDBERG DR, SLIDELL, LA 70458-8062
(985) 649-4063
Mailing address
4664 PAINTERS ST, NEW ORLEANS, LA 70122-5002
Taxonomy
Speciality
Code
Description
License number
State
367500000X
Certified Registered Nurse Anesthetist
Primary
07870
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
01676750
—
MS
05
—
2378040
—
LA
Enumeration date
09/16/2014
Last updated
02/24/2016
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