Provider Demographics
NPI:1932258456
Name:BROUSSARD, JOAN T (ACNP)
Entity Type:Individual
Prefix:MRS
First Name:JOAN
Middle Name:T
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:457 HEYMANN BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-2616
Mailing Address - Country:US
Mailing Address - Phone:337-237-5774
Mailing Address - Fax:
Practice Address - Street 1:917 COOLIDGE BLVD
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70503-2433
Practice Address - Country:US
Practice Address - Phone:337-237-5774
Practice Address - Fax:337-237-4939
Is Sole Proprietor?:No
Enumeration Date:2007-01-10
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN083622163W00000X
LAAP05141363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1408361Medicaid
LAAP05141OtherSTATE LICENSE