Provider Demographics
NPI:1396894689
Name:BROUILLETTE, ROBERT ELLIS (CRNA)
Entity type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:ELLIS
Last Name:BROUILLETTE
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5024 TOBY LN
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065-3262
Mailing Address - Country:US
Mailing Address - Phone:504-456-9958
Mailing Address - Fax:
Practice Address - Street 1:1057 PAUL MAILLARD RD
Practice Address - Street 2:
Practice Address - City:LULING
Practice Address - State:LA
Practice Address - Zip Code:70070-4349
Practice Address - Country:US
Practice Address - Phone:985-785-6242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN041094APO1427367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1904765Medicaid
LA1904765Medicaid