Active NPI
Michelle D Broussard, PHD, RDN, LD
- Registered Dietitian
- Ellenwood, GA
National Provider Identifier
1689551053
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Registered Dietitian
- License
- LD002261
- Practice address
- 4300 Ward Bluff Dr
Ellenwood, GA 30294-1783 - Phone
- (404) 216-2067
- NPI assigned
- Aug 18, 2025
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 5
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Nutrition Education Nutritionist | 133NN1002X | LD002261 | GA | |
| Dietary Manager | 132700000X | LD002261 | GA | |
| Renal Nutrition Registered Dietitian | 133VN1005X | LD00261 | GA | |
| Community Health Clinic/Center | 261QC1500X | LD002261 | GA | |
| Registered Dietitian | 133V00000X | LD002261 | GA | Primary |
Addresses
Primary practice location
4300 Ward Bluff Dr
Ellenwood, GA 30294-1783
Mailing address
4300 Ward Bluff Dr
Ellenwood, GA 30294-1783
Phone (404) 216-2067
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
- Credentials
- Doctor of Philosophy
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| LD00261 | GA | MD | Renal Nutrition Registered Dietitian |
| LD002261 | GA | MD | Community Health Clinic/Center |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1755475200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1755475200000",
"number": "1689551053",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "4300 WARD BLUFF DR",
"city": "ELLENWOOD",
"state": "GA",
"postal_code": "302941783",
"telephone_number": "404-216-2067"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "4300 WARD BLUFF DR",
"city": "ELLENWOOD",
"state": "GA",
"postal_code": "302941783",
"telephone_number": "404-216-2067"
}
],
"practiceLocations": [],
"basic": {
"last_name": "BROUSSARD",
"first_name": "MICHELLE",
"middle_name": "D",
"credential": "PHD, RDN, LD",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2025-08-18",
"last_updated": "2025-08-18",
"certification_date": "2025-08-18",
"status": "A"
},
"taxonomies": [
{
"code": "133NN1002X",
"taxonomy_group": "",
"desc": "Nutritionist, Nutrition, Education",
"state": "GA",
"license": "LD002261",
"primary": false
},
{
"code": "132700000X",
"taxonomy_group": "",
"desc": "Dietary Manager",
"state": "GA",
"license": "LD002261",
"primary": false
},
{
"code": "133VN1005X",
"taxonomy_group": "",
"desc": "Dietitian, Registered, Nutrition, Renal",
"state": "GA",
"license": "LD00261",
"primary": false
},
{
"code": "261QC1500X",
"taxonomy_group": "",
"desc": "Clinic/Center, Community Health",
"state": "GA",
"license": "LD002261",
"primary": false
},
{
"code": "133V00000X",
"taxonomy_group": "",
"desc": "Dietitian, Registered",
"state": "GA",
"license": "LD002261",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Ellenwood, GA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 18, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.