Provider Demographics
NPI:1619970308
Name:BROUSSARD, TRACY P (FNP)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:P
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:FNP
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 52028
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70505-2028
Mailing Address - Country:US
Mailing Address - Phone:337-354-0030
Mailing Address - Fax:337-354-0026
Practice Address - Street 1:155 HOSPITAL DR
Practice Address - Street 2:STE 100
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2852
Practice Address - Country:US
Practice Address - Phone:337-354-0030
Practice Address - Fax:337-354-0026
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN087132 AP04548363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily