Provider Demographics
NPI:1962652479
Name:BROUILLETTE, LESLIE ANNE (NP)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:ANNE
Last Name:BROUILLETTE
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:2350 W EL CAMINO REAL FL 2
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-6203
Mailing Address - Country:US
Mailing Address - Phone:707-541-7700
Mailing Address - Fax:707-573-5415
Practice Address - Street 1:131 STONY CIR STE 1600
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-9520
Practice Address - Country:US
Practice Address - Phone:707-541-7700
Practice Address - Fax:707-573-5415
Is Sole Proprietor?:No
Enumeration Date:2008-09-22
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA529152163WC0400X, 163WC1500X, 163WL0100X, 163WM0102X, 163WP0200X, 163WP1700X, 163WX0002X
CANP95001265363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No163WM0102XNursing Service ProvidersRegistered NurseMaternal Newborn
No163WP0200XNursing Service ProvidersRegistered NursePediatrics
No163WP1700XNursing Service ProvidersRegistered NursePerinatal
No163WX0002XNursing Service ProvidersRegistered NurseObstetric, High-Risk
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANP95001265OtherSTATE MEDICAL LICENSE
CAMB3360889OtherFEDERAL DEA LICENSE