Provider Demographics
NPI:1265034516
Name:BROUSSARD, SHANIKA
Entity Type:Individual
Prefix:
First Name:SHANIKA
Middle Name:
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 COWAN RD.
Mailing Address - Street 2:SUITE B #2014
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507
Mailing Address - Country:US
Mailing Address - Phone:228-254-3037
Mailing Address - Fax:228-335-6029
Practice Address - Street 1:6163 E LAMAR ST
Practice Address - Street 2:
Practice Address - City:BAY SAINT LOUIS
Practice Address - State:MS
Practice Address - Zip Code:39520-8267
Practice Address - Country:US
Practice Address - Phone:504-908-5893
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-11
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS372600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372600000XNursing Service Related ProvidersAdult Companion