Provider Demographics
NPI:1467167742
Name:BROUILLETTE, BRANT ALLEN
Entity Type:Individual
Prefix:
First Name:BRANT
Middle Name:ALLEN
Last Name:BROUILLETTE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58396 HEMMINGER DR
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46528-9130
Mailing Address - Country:US
Mailing Address - Phone:574-536-2070
Mailing Address - Fax:
Practice Address - Street 1:58396 HEMMINGER DR
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46528-9130
Practice Address - Country:US
Practice Address - Phone:574-536-2070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-20
Last Update Date:2023-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer