Provider Demographics
NPI:1396453205
Name:BROUILLARD, DANIELLE ALISON (MSN, AGACNP-BC, OCN)
Entity type:Individual
Prefix:MS
First Name:DANIELLE
Middle Name:ALISON
Last Name:BROUILLARD
Suffix:
Gender:F
Credentials:MSN, AGACNP-BC, OCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2314 SE 46TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-3738
Mailing Address - Country:US
Mailing Address - Phone:603-380-1771
Mailing Address - Fax:
Practice Address - Street 1:3485 S BOND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4503
Practice Address - Country:US
Practice Address - Phone:503-494-8311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-09
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202213884RN163W00000X
OR10002086363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR10002086OtherAPRN LICENSE