Provider Demographics
NPI:1104368968
Name:DAVIS, MARANDA BROWN (HAIRLOSS SPECIALIST)
Entity Type:Individual
Prefix:
First Name:MARANDA
Middle Name:BROWN
Last Name:DAVIS
Suffix:
Gender:F
Credentials:HAIRLOSS SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2757 LAUREL ST
Mailing Address - Street 2:3
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29204-2037
Mailing Address - Country:US
Mailing Address - Phone:803-730-0231
Mailing Address - Fax:
Practice Address - Street 1:2757 LAUREL ST
Practice Address - Street 2:3
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29204-2037
Practice Address - Country:US
Practice Address - Phone:803-730-0231
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-10
Last Update Date:2016-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1744P3200X1744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC1744P3200XOtherHAIRLOSS SPECIALIST