Provider Demographics
NPI:1053615773
Name:BROUSSEAU, LUZ MARIA (LPN)
Entity type:Individual
Prefix:MRS
First Name:LUZ
Middle Name:MARIA
Last Name:BROUSSEAU
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MISS
Other - First Name:LUZ
Other - Middle Name:MARIA
Other - Last Name:ESPINOZA MUNIZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:600 NE 8TH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-7318
Mailing Address - Country:US
Mailing Address - Phone:503-988-8500
Mailing Address - Fax:
Practice Address - Street 1:600 NE 8TH ST STE 300
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-7318
Practice Address - Country:US
Practice Address - Phone:503-988-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-10
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201030226164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR201030226LPNOtherLICENSE PRACTICAL NURSE