Provider Demographics
NPI:1275357634
Name:BRASSELL, IESHA
Entity type:Individual
Prefix:
First Name:IESHA
Middle Name:
Last Name:BRASSELL
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 1:9612 HAZELTON
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48239-1480
Mailing Address - Country:US
Mailing Address - Phone:313-346-3971
Mailing Address - Fax:
Practice Address - Street 1:9612 HAZELTON
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48239-1480
Practice Address - Country:US
Practice Address - Phone:313-346-3971
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-12
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
372500000X
MI172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No372500000XNursing Service Related ProvidersChore Provider