Provider Demographics
NPI:1669827192
Name:BROUSSARD, DANIELLE MARIE DESORMEAUX (AGACNP)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:MARIE DESORMEAUX
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:DANIELLE
Other - Middle Name:MARIE
Other - Last Name:DESORMEAUX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AGACNP
Mailing Address - Street 1:4140 W 190TH ST
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-5513
Mailing Address - Country:US
Mailing Address - Phone:310-423-4208
Mailing Address - Fax:310-959-3332
Practice Address - Street 1:8700 BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90048-1804
Practice Address - Country:US
Practice Address - Phone:310-423-4208
Practice Address - Fax:310-959-3332
Is Sole Proprietor?:No
Enumeration Date:2016-05-03
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95004454363LA2100X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care