Provider Demographics
NPI:1093192791
Name:BROWN, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
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 1:30 YORKSHIRE PKWY
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-4018
Mailing Address - Country:US
Mailing Address - Phone:228-563-3501
Mailing Address - Fax:228-206-6444
Practice Address - Street 1:30 YORKSHIRE PKWY
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-4018
Practice Address - Country:US
Practice Address - Phone:228-563-3501
Practice Address - Fax:228-206-6444
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-01
Last Update Date:2016-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSDOM05768251E00000X, 252Y00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No252Y00000XAgenciesEarly Intervention Provider Agency
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSDOM05768OtherTHE DIVISION OF MEDICAID AND THE ARC OF MISSISSIPPI/CERTIFICATION