Provider Demographics
NPI:1689870263
Name:BREAUX, MICHELLE B (NP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:B
Last Name:BREAUX
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:RENE
Other - Last Name:BERGERON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8415 GOODWOOD BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70806-7851
Mailing Address - Country:US
Mailing Address - Phone:225-765-5633
Mailing Address - Fax:225-765-5634
Practice Address - Street 1:8415 GOODWOOD BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70806-7851
Practice Address - Country:US
Practice Address - Phone:225-765-5633
Practice Address - Fax:225-765-5634
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2021-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN105312 AP04932363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1015695Medicaid
LA1015695Medicaid
LA3B495D279Medicare PIN