Provider Demographics
NPI:1033180997
Name:BROUILLETTE, CHARLENE V (CRNA)
Entity Type:Individual
Prefix:MS
First Name:CHARLENE
Middle Name:V
Last Name:BROUILLETTE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5024 TOBY LN
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065-3262
Mailing Address - Country:US
Mailing Address - Phone:504-456-9958
Mailing Address - Fax:504-779-6769
Practice Address - Street 1:5024 TOBY LN
Practice Address - Street 2:
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70065-3262
Practice Address - Country:US
Practice Address - Phone:504-456-9958
Practice Address - Fax:504-779-6769
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP02363367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1905356Medicaid
LAR15905Medicare UPIN
LA56417CQ68Medicare PIN
LA56417Medicare ID - Type Unspecified