Provider Demographics
NPI:1154469534
Name:GILBERT, SHELLY BROUSSARD (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:SHELLY
Middle Name:BROUSSARD
Last Name:GILBERT
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 1:13523 BARRETT PARKWAY DRIVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021-3802
Mailing Address - Country:US
Mailing Address - Phone:636-938-6868
Mailing Address - Fax:636-938-1486
Practice Address - Street 1:1757 IMPERIAL BLVD.
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605
Practice Address - Country:US
Practice Address - Phone:337-310-2832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-01
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN071326367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4B584OtherMEDICARE SERVICES PART B