Provider Demographics
NPI:1639672561
Name:BRISENO, NICOLE MARIE (LVN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:BRISENO
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:GONZALES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4395 FM 2504
Mailing Address - Street 2:
Mailing Address - City:POTEET
Mailing Address - State:TX
Mailing Address - Zip Code:78065
Mailing Address - Country:US
Mailing Address - Phone:210-213-0797
Mailing Address - Fax:
Practice Address - Street 1:7330 SAN PEDRO AVE
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-6235
Practice Address - Country:US
Practice Address - Phone:210-737-8090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-16
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX314705164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse