Healthcare Provider Details

I. General information

NPI: 1609879659
Provider Name (Legal Business Name): GLENDA CAROL BREAKFELL PETROFF FNPC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 01/28/2008
Certification Date:
Deactivation Date: 05/23/2005
Reactivation Date: 05/24/2005

III. Provider practice location address

22070 HIGHWAY 59
ABITA SPRINGS LA
70420
US

IV. Provider business mailing address

1514 JEFFERSON HWY
NEW ORLEANS LA
70121
US

V. Phone/Fax

Practice location:
  • Phone: 985-892-0879
  • Fax: 985-875-2384
Mailing address:
  • Phone: 504-842-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN099641
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN099641AP03834
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: