Provider Demographics
NPI:1710209044
Name:BROUSSARD, AIMEE C (APRN)
Entity Type:Individual
Prefix:
First Name:AIMEE
Middle Name:C
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P O BOX 1317
Mailing Address - Street 2:
Mailing Address - City:BROUSSARD
Mailing Address - State:LA
Mailing Address - Zip Code:70518-1317
Mailing Address - Country:US
Mailing Address - Phone:337-330-4730
Mailing Address - Fax:337-330-4732
Practice Address - Street 1:805 ALBERTSON PKWY STE A
Practice Address - Street 2:
Practice Address - City:BROUSSARD
Practice Address - State:LA
Practice Address - Zip Code:70518-4350
Practice Address - Country:US
Practice Address - Phone:337-330-4730
Practice Address - Fax:337-330-4732
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-01
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN094687-AP06057363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2100190Medicaid