Provider Demographics
NPI:1861294167
Name:BROUSSARD, LORI (LVN)
Entity type:Individual
Prefix:
First Name:LORI
Middle Name:
Last Name:BROUSSARD
Suffix:
Gender:
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15516 IRON CANYON RD
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91387-4746
Mailing Address - Country:US
Mailing Address - Phone:213-723-8109
Mailing Address - Fax:
Practice Address - Street 1:14149 BUCHER AVE # RPT-D
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-1442
Practice Address - Country:US
Practice Address - Phone:747-999-4232
Practice Address - Fax:818-479-7549
Is Sole Proprietor?:No
Enumeration Date:2025-03-26
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA272933164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse