Provider Demographics
NPI:1962628156
Name:BROUSSARD, BRENDA A (RD, CDE, BC-ADM)
Entity Type:Individual
Prefix:MS
First Name:BRENDA
Middle Name:A
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:RD, CDE, BC-ADM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 BERM ST NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-1822
Mailing Address - Country:US
Mailing Address - Phone:505-792-0065
Mailing Address - Fax:505-792-0488
Practice Address - Street 1:PRESBYTERIAN FAMILY PRACTICE MEDICAL GROUP
Practice Address - Street 2:3901 ATRISCO
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120
Practice Address - Country:US
Practice Address - Phone:505-462-7575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM036133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic