Provider Demographics
NPI:1891151023
Name:BRISENO, DAISY (FNP)
Entity Type:Individual
Prefix:
First Name:DAISY
Middle Name:
Last Name:BRISENO
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 241011
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95241-9511
Mailing Address - Country:US
Mailing Address - Phone:209-339-7435
Mailing Address - Fax:209-333-3054
Practice Address - Street 1:2415 W VINE ST
Practice Address - Street 2:SUITE 106
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-3731
Practice Address - Country:US
Practice Address - Phone:209-333-3066
Practice Address - Fax:209-333-3065
Is Sole Proprietor?:No
Enumeration Date:2016-01-04
Last Update Date:2017-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA810710163W00000X
CA95003972363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily