Provider Demographics
NPI:1801386206
Name:BRISSEAU, SHIRRON E
Entity Type:Individual
Prefix:MS
First Name:SHIRRON
Middle Name:E
Last Name:BRISSEAU
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 1:346 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-4447
Mailing Address - Country:US
Mailing Address - Phone:757-350-4477
Mailing Address - Fax:
Practice Address - Street 1:346 N. MAIN ST
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434
Practice Address - Country:US
Practice Address - Phone:757-350-4477
Practice Address - Fax:757-350-4488
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-11
Last Update Date:2018-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1669865291Medicaid