Healthcare Provider Details

I. General information

NPI: 1427155019
Provider Name (Legal Business Name): GLENN CORMIER CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2006
Last Update Date: 03/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8212 KELWOOD AVE
BATON ROUGE LA
70806-4801
US

IV. Provider business mailing address

2644 S SHERWOOD FOREST BLVD STE 121
BATON ROUGE LA
70816-2248
US

V. Phone/Fax

Practice location:
  • Phone: 225-929-7600
  • Fax: 225-930-7524
Mailing address:
  • Phone: 225-293-2523
  • Fax: 225-293-1807

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number036468
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: