Provider Demographics
NPI:1205125481
Name:BRISSETTE, DIANA (ASSOCIATES)
Entity type:Individual
Prefix:MISS
First Name:DIANA
Middle Name:
Last Name:BRISSETTE
Suffix:
Gender:F
Credentials:ASSOCIATES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 N WALKER ST
Mailing Address - Street 2:
Mailing Address - City:TAUNTON
Mailing Address - State:MA
Mailing Address - Zip Code:02780-2145
Mailing Address - Country:US
Mailing Address - Phone:508-863-4444
Mailing Address - Fax:
Practice Address - Street 1:184 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:NORTH EASTON
Practice Address - State:MA
Practice Address - Zip Code:02356-1799
Practice Address - Country:US
Practice Address - Phone:508-238-7053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-28
Last Update Date:2011-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA353302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization