Provider Demographics
NPI:1730558313
Name:BROUSSARD, KENDRA (WHNP, AGPCNP, RN)
Entity type:Individual
Prefix:
First Name:KENDRA
Middle Name:
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:WHNP, AGPCNP, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 SAXTON ST UNIT 2
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02125-1439
Mailing Address - Country:US
Mailing Address - Phone:781-264-4753
Mailing Address - Fax:
Practice Address - Street 1:101 COURT ST STE 8
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-8718
Practice Address - Country:US
Practice Address - Phone:508-732-7327
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-24
Last Update Date:2018-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2292034363LA2200X, 363LG0600X, 363LW0102X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health