Provider Demographics
NPI:1104860907
Name:BROWN, RONNIE KEITH (NP)
Entity Type:Individual
Prefix:
First Name:RONNIE
Middle Name:KEITH
Last Name:BROWN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:965 RIDGE LAKE BLVD STE 315
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38120-9401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:901-227-8591
Practice Address - Street 1:1100 HIGHWAY 16 E
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:MS
Practice Address - Zip Code:39051
Practice Address - Country:US
Practice Address - Phone:601-253-0173
Practice Address - Fax:601-346-2352
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2021-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR805591363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00122364Medicaid
AL180350Medicaid
MSP00205128OtherRAILROAD MEDICARE
AL180350Medicaid
MSP01435649Medicare PIN
MS255623YJ5DMedicare PIN
MSP00205128OtherRAILROAD MEDICARE
MS302I508589Medicare PIN
AL180350Medicaid