Provider Demographics
NPI:1801479019
Name:DISIMONE, BRENDA ANN (CPHT)
Entity type:Individual
Prefix:
First Name:BRENDA
Middle Name:ANN
Last Name:DISIMONE
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2213 TAFFY DR
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065-3861
Mailing Address - Country:US
Mailing Address - Phone:504-232-0177
Mailing Address - Fax:
Practice Address - Street 1:8912 VETERANS MEMORIAL BLVD
Practice Address - Street 2:
Practice Address - City:METAIRIE
Practice Address - State:LA
Practice Address - Zip Code:70003-5200
Practice Address - Country:US
Practice Address - Phone:504-465-0171
Practice Address - Fax:504-465-9047
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-04
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA007653183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician