Provider Demographics
NPI:1467749754
Name:WOULLARD-BRELAND, LORI CRYSTAL (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:LORI
Middle Name:CRYSTAL
Last Name:WOULLARD-BRELAND
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:CRYSTAL
Other - Last Name:WOULLARD-BRELAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-579-5463
Mailing Address - Fax:601-579-5240
Practice Address - Street 1:415 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7246
Practice Address - Country:US
Practice Address - Phone:601-261-3606
Practice Address - Fax:601-579-5383
Is Sole Proprietor?:No
Enumeration Date:2011-07-07
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR859468367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07527007Medicaid
MS3476675OtherUNITED HEALTHCARE
MS9369843OtherAETNA
MS6655503OtherCIGNA
MS3476675OtherUNITED HEALTHCARE