Provider Demographics
NPI:1023100641
Name:BRASURE, DONIELLE LYNN (MPT)
Entity type:Individual
Prefix:MRS
First Name:DONIELLE
Middle Name:LYNN
Last Name:BRASURE
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:232 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:MILLVILLE
Mailing Address - State:DE
Mailing Address - Zip Code:19967-6728
Mailing Address - Country:US
Mailing Address - Phone:302-539-3110
Mailing Address - Fax:302-539-7237
Practice Address - Street 1:232 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:MILLVILLE
Practice Address - State:DE
Practice Address - Zip Code:19967-6728
Practice Address - Country:US
Practice Address - Phone:302-539-3110
Practice Address - Fax:302-539-7237
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ10001969225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1023100641Medicaid
DE1023100641Medicaid