Provider Demographics
NPI:1164504981
Name:BROUILLETTE, LAURA V (CRNA)
Entity Type:Individual
Prefix:
First Name:LAURA
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 1:235 BALSAM LN
Mailing Address - Street 2:
Mailing Address - City:ISHPEMING
Mailing Address - State:MI
Mailing Address - Zip Code:49849-2710
Mailing Address - Country:US
Mailing Address - Phone:906-485-1043
Mailing Address - Fax:
Practice Address - Street 1:580 W COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2705
Practice Address - Country:US
Practice Address - Phone:906-228-9440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704229292367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MILA075196OtherBLUESHIELD PIN
MI104865802Medicaid
MI104865802Medicaid
MIE26018029Medicare PIN