Healthcare Provider Details

I. General information

NPI: 1295073781
Provider Name (Legal Business Name): JUSTIN M VERMEULEN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2013
Last Update Date: 10/13/2025
Certification Date: 10/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8212 SUMMA AVE
BATON ROUGE LA
70809-3421
US

IV. Provider business mailing address

PO BOX 776351
CHICAGO IL
60677-6351
US

V. Phone/Fax

Practice location:
  • Phone: 225-769-4403
  • Fax:
Mailing address:
  • Phone: 502-588-9490
  • Fax: 502-272-5116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number3016642
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: