Provider Demographics
NPI:1841581949
Name:BROUILLETTE, GRACE (DO)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:BROUILLETTE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4520 NE 46TH ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64117-1308
Mailing Address - Country:US
Mailing Address - Phone:816-726-5985
Mailing Address - Fax:
Practice Address - Street 1:3901 RAINBOW BLVD # MS 4004
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66103-2937
Practice Address - Country:US
Practice Address - Phone:913-588-6917
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-22
Last Update Date:2014-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05-37216208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics