Provider Demographics
NPI:1083178321
Name:BROWN, MARY H (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:H
Last Name:BROWN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2045 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:STATHAM
Mailing Address - State:GA
Mailing Address - Zip Code:30666-1712
Mailing Address - Country:US
Mailing Address - Phone:678-491-1123
Mailing Address - Fax:
Practice Address - Street 1:1360 CADUCEUS WAY BLDG 400-104
Practice Address - Street 2:
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-7351
Practice Address - Country:US
Practice Address - Phone:706-850-8135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-30
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN239142363LA2100X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered Nurse
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Multi-Specialty