Provider Demographics
NPI:1942186515
Name:BRISCO, TIAIRA NICOLE
Entity type:Individual
Prefix:
First Name:TIAIRA
Middle Name:NICOLE
Last Name:BRISCO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:910 JOANNE CT APT C
Mailing Address - Street 2:
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-2718
Mailing Address - Country:US
Mailing Address - Phone:707-848-0348
Mailing Address - Fax:
Practice Address - Street 1:910 JOANNE CT APT C
Practice Address - Street 2:
Practice Address - City:ROHNERT PARK
Practice Address - State:CA
Practice Address - Zip Code:94928-2718
Practice Address - Country:US
Practice Address - Phone:707-848-0348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-11
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA93331225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist