Provider Demographics
NPI:1033468673
Name:BRISEUS, WIDLINE DANIELLE
Entity Type:Individual
Prefix:
First Name:WIDLINE
Middle Name:DANIELLE
Last Name:BRISEUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22415 SW 61ST WAY
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33428
Mailing Address - Country:US
Mailing Address - Phone:561-860-3766
Mailing Address - Fax:
Practice Address - Street 1:22415 SW 61ST WAY
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33428
Practice Address - Country:US
Practice Address - Phone:561-860-3766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-29
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife