Provider Demographics
NPI:1083486187
Name:BROUELETTE, SERENA
Entity Type:Individual
Prefix:
First Name:SERENA
Middle Name:
Last Name:BROUELETTE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 CAMELBACK ST
Mailing Address - Street 2:PO BOX #10293
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92658
Mailing Address - Country:US
Mailing Address - Phone:949-485-0215
Mailing Address - Fax:
Practice Address - Street 1:360 SAN MIGUEL DR STE 406
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7822
Practice Address - Country:US
Practice Address - Phone:949-525-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-23
Last Update Date:2024-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant