Healthcare Provider Details

I. General information

NPI: 1720172539
Provider Name (Legal Business Name): DEENA R BRISSETT FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DEENA ELIZALDE

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 07/22/2022
Certification Date: 07/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1811 CHARLTON CT
GOSHEN IN
46526-6464
US

IV. Provider business mailing address

1811 CHARLTON CT
GOSHEN IN
46526-6464
US

V. Phone/Fax

Practice location:
  • Phone: 574-534-8200
  • Fax: 574-534-0411
Mailing address:
  • Phone: 574-534-8200
  • Fax: 574-534-0411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71001310A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number622215
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: