Provider Demographics
NPI:1629199609
Name:BRASIL, DIANA LYN
Entity Type:Individual
Prefix:
First Name:DIANA
Middle Name:LYN
Last Name:BRASIL
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 1:9935 LYONS RD
Mailing Address - Street 2:
Mailing Address - City:RIPON
Mailing Address - State:CA
Mailing Address - Zip Code:95366-9623
Mailing Address - Country:US
Mailing Address - Phone:209-923-7938
Mailing Address - Fax:
Practice Address - Street 1:1400 K ST
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95354-1018
Practice Address - Country:US
Practice Address - Phone:209-550-5869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program