Provider Demographics
NPI:1023864618
Name:BROUSSARD, JOHN ADAM JR (LVN)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ADAM
Last Name:BROUSSARD
Suffix:JR
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5105 HEATHER RANCH WAY
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95742-8180
Mailing Address - Country:US
Mailing Address - Phone:916-494-8511
Mailing Address - Fax:
Practice Address - Street 1:10089 FOLSOM BLVD STE A
Practice Address - Street 2:
Practice Address - City:RANCHO CORDOVA
Practice Address - State:CA
Practice Address - Zip Code:95670-1935
Practice Address - Country:US
Practice Address - Phone:916-366-6531
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-25
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN150240164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse