Provider Demographics
NPI:1720172539
Name:BRISSETT, DEENA R (FNP)
Entity Type:Individual
Prefix:MS
First Name:DEENA
Middle Name:R
Last Name:BRISSETT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:DEENA
Other - Middle Name:
Other - Last Name:ELIZALDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1811 CHARLTON CT
Mailing Address - Street 2:
Mailing Address - City:GOSHEN
Mailing Address - State:IN
Mailing Address - Zip Code:46526-6464
Mailing Address - Country:US
Mailing Address - Phone:574-534-8200
Mailing Address - Fax:574-534-0411
Practice Address - Street 1:1811 CHARLTON CT
Practice Address - Street 2:
Practice Address - City:GOSHEN
Practice Address - State:IN
Practice Address - Zip Code:46526-6464
Practice Address - Country:US
Practice Address - Phone:574-534-8200
Practice Address - Fax:574-534-0411
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71001310A363LF0000X
TX622215363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX180329801Medicaid
TX8G0302Medicare ID - Type Unspecified