Provider Demographics
NPI:1790305415
Name:ROUSSEAU, RAECENE CHANTAI (DNP)
Entity type:Individual
Prefix:DR
First Name:RAECENE
Middle Name:CHANTAI
Last Name:ROUSSEAU
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1075 TOWN CENTER DR
Mailing Address - Street 2:
Mailing Address - City:ORANGE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32763-8360
Mailing Address - Country:US
Mailing Address - Phone:386-917-0333
Mailing Address - Fax:386-917-0336
Practice Address - Street 1:1075 TOWN CENTER DR
Practice Address - Street 2:
Practice Address - City:ORANGE CITY
Practice Address - State:FL
Practice Address - Zip Code:32763-8360
Practice Address - Country:US
Practice Address - Phone:386-917-0333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-22
Last Update Date:2025-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11004481363LA2100X
NYF345850363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL117015300Medicaid