Provider Demographics
NPI:1013173343
Name:BROUILLETTE, PAULLA DANIELLE (PA)
Entity Type:Individual
Prefix:
First Name:PAULLA
Middle Name:DANIELLE
Last Name:BROUILLETTE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7777 HENNESSY BLVD
Mailing Address - Street 2:OUR LADY OF THE LAKE MED CNTR -- ER DEPT
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-4300
Mailing Address - Country:US
Mailing Address - Phone:888-447-2450
Mailing Address - Fax:405-341-9217
Practice Address - Street 1:7777 HENNESSY BLVD
Practice Address - Street 2:OUR LADY OF THE LAKE MED CNTR -- ER DEPT
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4300
Practice Address - Country:US
Practice Address - Phone:888-447-2450
Practice Address - Fax:405-341-9217
Is Sole Proprietor?:No
Enumeration Date:2008-08-06
Last Update Date:2013-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA.200216363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1319376Medicaid
P00810364OtherRAILROAD THRU PEPA
LA1319376Medicaid
LA1319376Medicaid