Provider Demographics
NPI:1184122145
Name:BROUSSARD, JAMILIA LASHAWN (MSN RN FNP-BC WCC)
Entity type:Individual
Prefix:MRS
First Name:JAMILIA
Middle Name:LASHAWN
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:MSN RN FNP-BC WCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 678219
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75267-8219
Mailing Address - Country:US
Mailing Address - Phone:214-970-6817
Mailing Address - Fax:844-803-4513
Practice Address - Street 1:1001 12TH AVE NW
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-5712
Practice Address - Country:US
Practice Address - Phone:580-220-6290
Practice Address - Fax:580-220-6215
Is Sole Proprietor?:No
Enumeration Date:2018-01-24
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX821209363LF0000X
TXAP136689363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily