Provider Demographics
NPI:1720012859
Name:ROUSSEL, TONI W (FNP)
Entity Type:Individual
Prefix:
First Name:TONI
Middle Name:W
Last Name:ROUSSEL
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 1:720 LEFORT BYPASS RD
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-6133
Mailing Address - Country:US
Mailing Address - Phone:985-257-0592
Mailing Address - Fax:
Practice Address - Street 1:10771 PERKINS RD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70810-1693
Practice Address - Country:US
Practice Address - Phone:225-256-1634
Practice Address - Fax:225-384-5402
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2020-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP04744363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1725251Medicaid
LA1725251Medicaid