Individual
EBONY ROUSSELL
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
931 CARMADELLE ST, MARRERO, LA 70072-2641
(504) 510-7951
Mailing address
931 CARMADELLE ST, MARRERO, LA 70072-2641
(504) 510-7951
Taxonomy
Speciality
Code
Description
License number
State
172A00000X
Driver
Primary
—
LA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
825114453
—
LA
Enumeration date
04/12/2018
Last updated
04/12/2018
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