Provider Demographics
NPI:1073016382
Name:BROWN, AUDREY O
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:O
Last Name:BROWN
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 1:2926 SLAGLES ROAD
Mailing Address - Street 2:
Mailing Address - City:EMPORIA
Mailing Address - State:VA
Mailing Address - Zip Code:23847
Mailing Address - Country:US
Mailing Address - Phone:434-632-0584
Mailing Address - Fax:
Practice Address - Street 1:2926 SLAGLES ROAD
Practice Address - Street 2:
Practice Address - City:EMPORIA
Practice Address - State:VA
Practice Address - Zip Code:23847
Practice Address - Country:US
Practice Address - Phone:434-632-0584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-13
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT24658673347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA$$$$$$$$$Medicaid