Provider Demographics
NPI:1245646850
Name:BRASUELL, DIANE MARISSA (DO)
Entity type:Individual
Prefix:
First Name:DIANE
Middle Name:MARISSA
Last Name:BRASUELL
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3905 SOUTH LAKE BLVD.
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37920-1511
Mailing Address - Country:US
Mailing Address - Phone:408-309-9493
Mailing Address - Fax:
Practice Address - Street 1:1924 ALCOA HWY # U-67
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37920-1511
Practice Address - Country:US
Practice Address - Phone:865-305-9350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-02
Last Update Date:2017-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN2963207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program