Provider Demographics
NPI:1780186221
Name:RISSER, BROOKLYN NICHOLE
Entity Type:Individual
Prefix:
First Name:BROOKLYN
Middle Name:NICHOLE
Last Name:RISSER
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 1:252 PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:DOWNINGTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19335
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:252 PARK DRIVE
Practice Address - Street 2:
Practice Address - City:DOWNINGTOWN
Practice Address - State:PA
Practice Address - Zip Code:19335
Practice Address - Country:US
Practice Address - Phone:717-875-2785
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-01
Last Update Date:2018-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer