Provider Demographics
NPI:1689551053
Name:BROUSSARD, MICHELLE D (PHD, RDN, LD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:D
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:PHD, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4300 WARD BLUFF DR
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-1783
Mailing Address - Country:US
Mailing Address - Phone:404-216-2067
Mailing Address - Fax:
Practice Address - Street 1:4300 WARD BLUFF DR
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294-1783
Practice Address - Country:US
Practice Address - Phone:404-216-2067
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-18
Last Update Date:2025-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002261133NN1002X, 132700000X, 261QC1500X, 133V00000X
GALD00261133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No132700000XDietary & Nutritional Service ProvidersDietary Manager
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health