1669827192 NPI number — DANIELLE MARIE DESORMEAUX BROUSSARD AGACNP

Table of content: DANIELLE MARIE DESORMEAUX BROUSSARD AGACNP (NPI 1669827192)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669827192 NPI number — DANIELLE MARIE DESORMEAUX BROUSSARD AGACNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROUSSARD
Provider First Name:
DANIELLE
Provider Middle Name:
MARIE DESORMEAUX
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AGACNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
DESORMEAUX
Provider Other First Name:
DANIELLE
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
AGACNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1669827192
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/24/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4140 W 190TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TORRANCE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90504-5513
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
310-423-4208
Provider Business Mailing Address Fax Number:
310-959-3332

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8700 BEVERLY BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST HOLLYWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90048-1804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-423-4208
Provider Business Practice Location Address Fax Number:
310-959-3332
Provider Enumeration Date:
05/03/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2100X , with the licence number:  NP95004454 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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