Provider Demographics
NPI:1174021646
Name:BROWN, MARY ANNE (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANNE
Last Name:BROWN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10895 MAGNOLIA AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-3057
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:951-602-4386
Practice Address - Street 1:10895 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-3057
Practice Address - Country:US
Practice Address - Phone:951-202-1863
Practice Address - Fax:951-602-4386
Is Sole Proprietor?:No
Enumeration Date:2018-01-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13982363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA13982OtherNURSE PRACTITIONER NUMBER
CA13982OtherNURSE PRACTITIONER NUMBER