Provider Demographics
NPI:1457306524
Name:BROUSSARD, BECKY ANN (CRNA)
Entity Type:Individual
Prefix:
First Name:BECKY
Middle Name:ANN
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 650426
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-0426
Mailing Address - Country:US
Mailing Address - Phone:213-345-7175
Mailing Address - Fax:
Practice Address - Street 1:8200 WALNUT HILL LN
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75231-4426
Practice Address - Country:US
Practice Address - Phone:213-345-7175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX676092367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX155545001Medicaid
TX82953UOtherBCBS TX
TX430077685OtherRAILROAD MEDICARE
TX88448HMedicare PIN