Provider Demographics
NPI:1437151636
Name:MAYEUX, ROMONA BROUSSARD (FNP-BC)
Entity Type:Individual
Prefix:MS
First Name:ROMONA
Middle Name:BROUSSARD
Last Name:MAYEUX
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:248 E CAPITOL ST
Mailing Address - Street 2:ROOM 105
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39201-2503
Mailing Address - Country:US
Mailing Address - Phone:601-714-2563
Mailing Address - Fax:601-510-4653
Practice Address - Street 1:248 E CAPITOL ST
Practice Address - Street 2:ROOM 105
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39201-2503
Practice Address - Country:US
Practice Address - Phone:601-714-2563
Practice Address - Fax:601-510-4653
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN041380 AP01824363LF0000X
MSR881289363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAAP01824OtherAPN LICENSE NUMBER
LA1655244Medicaid
MSR881289OtherMISSISSIPPI STATES BOARD OF NURSING
LARN041380OtherRN LICENSE NUMBER
MSR881289OtherMISSISSIPPI STATES BOARD OF NURSING
LA1655244Medicaid