Provider Demographics
NPI:1205323524
Name:BROUSSARD, TARESSA ANNE (NP)
Entity type:Individual
Prefix:
First Name:TARESSA
Middle Name:ANNE
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-757-0343
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:7777 HENNESSY BLVD STE 6000
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4366
Practice Address - Country:US
Practice Address - Phone:225-757-0343
Practice Address - Fax:225-757-8354
Is Sole Proprietor?:No
Enumeration Date:2018-04-23
Last Update Date:2024-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP09838363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner