Provider Demographics
NPI:1407481393
Name:BROOMFIELD, DEJAE ANTRELL
Entity Type:Individual
Prefix:
First Name:DEJAE
Middle Name:ANTRELL
Last Name:BROOMFIELD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:320 PROGRESSIVE BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-4069
Mailing Address - Country:US
Mailing Address - Phone:985-303-6090
Mailing Address - Fax:985-872-0985
Practice Address - Street 1:320 PROGRESSIVE BLVD
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-4069
Practice Address - Country:US
Practice Address - Phone:985-303-6090
Practice Address - Fax:985-872-0985
Is Sole Proprietor?:No
Enumeration Date:2020-03-11
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant