Provider Demographics
NPI:1659740793
Name:BROUSSARD, ALEXANDRA
Entity Type:Individual
Prefix:
First Name:ALEXANDRA
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 1:13313 N. MERIDAN
Mailing Address - Street 2:SUITE A3
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120
Mailing Address - Country:US
Mailing Address - Phone:405-753-9600
Mailing Address - Fax:405-753-9601
Practice Address - Street 1:13313 N. MERIDAN
Practice Address - Street 2:SUITE A3
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120
Practice Address - Country:US
Practice Address - Phone:405-753-9600
Practice Address - Fax:405-753-9601
Is Sole Proprietor?:No
Enumeration Date:2015-09-18
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK103887163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse