Provider Demographics
NPI:1124601026
Name:BROUSSARD, SHELLEY (RN,BSN,IBCLC)
Entity Type:Individual
Prefix:
First Name:SHELLEY
Middle Name:
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:RN,BSN,IBCLC
Other - Prefix:
Other - First Name:SHELLEY
Other - Middle Name:
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4704 AMBASSADOR CAFFERY PKWY FL PAKWAY2
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-6908
Mailing Address - Country:US
Mailing Address - Phone:337-470-5594
Mailing Address - Fax:
Practice Address - Street 1:4630 AMBASSADOR CAFFERY PKWY STE 204
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-6949
Practice Address - Country:US
Practice Address - Phone:337-470-5546
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-29
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA48443163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant