Provider Demographics
NPI:1609879659
Name:PETROFF, GLENDA CAROL BREAKFELL (FNPC)
Entity Type:Individual
Prefix:
First Name:GLENDA
Middle Name:CAROL BREAKFELL
Last Name:PETROFF
Suffix:
Gender:F
Credentials:FNPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:
Practice Address - Street 1:22070 HIGHWAY 59
Practice Address - Street 2:
Practice Address - City:ABITA SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70420
Practice Address - Country:US
Practice Address - Phone:985-892-0879
Practice Address - Fax:985-875-2384
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-23
Last Update Date:2008-01-28
Deactivation Date:2005-05-23
Deactivation Code:
Reactivation Date:2005-05-24
Provider Licenses
StateLicense IDTaxonomies
LARN099641363LF0000X
LARN099641AP03834363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1128139Medicaid
P00239061OtherRR MEDICARE
MS07931777Medicaid
P00239061OtherRR MEDICARE
LAG65207Medicare UPIN
LA1128139Medicaid