Healthcare Provider Details

I. General information

NPI: 1902440936
Provider Name (Legal Business Name): BRIANA DESHUN DYSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2019
Last Update Date: 11/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11616 SOUTHFORK AVE
BATON ROUGE LA
70816-5241
US

IV. Provider business mailing address

8928 SMOKE ROCK DR
BATON ROUGE LA
70817-6952
US

V. Phone/Fax

Practice location:
  • Phone: 225-291-9646
  • Fax:
Mailing address:
  • Phone: 225-328-2303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: