Provider Demographics
NPI:1174632954
Name:BROUSSARD, LAURA (APRN)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:FORBES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:820 N CHELAN AVE
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-2028
Mailing Address - Country:US
Mailing Address - Phone:509-663-8711
Mailing Address - Fax:
Practice Address - Street 1:103 CAMELIA ST
Practice Address - Street 2:
Practice Address - City:ROYAL CITY
Practice Address - State:WA
Practice Address - Zip Code:99357
Practice Address - Country:US
Practice Address - Phone:509-663-8711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61075750363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200069810AMedicaid