Provider Demographics
NPI:1659601607
Name:BROUSSARD, MARLA (CRNA)
Entity Type:Individual
Prefix:MS
First Name:MARLA
Middle Name:
Last Name:BROUSSARD
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 1:816 INDEPENDENCE BLVD
Mailing Address - Street 2:STE. 2A
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455-6010
Mailing Address - Country:US
Mailing Address - Phone:757-363-6230
Mailing Address - Fax:757-363-6204
Practice Address - Street 1:816 INDEPENDENCE BLVD
Practice Address - Street 2:STE. 2A
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-6010
Practice Address - Country:US
Practice Address - Phone:757-363-6230
Practice Address - Fax:757-363-6204
Is Sole Proprietor?:No
Enumeration Date:2010-01-13
Last Update Date:2011-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX079980367500000X
VA0024169450367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
079980OtherCRNA LICENSE NUMBER
TX768704OtherTX NURSING LICENSE