Provider Demographics
NPI:1194005199
Name:BROWN, MICHELLE W (PPCNP-BC)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:W
Last Name:BROWN
Suffix:
Gender:F
Credentials:PPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 746645
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6645
Mailing Address - Country:US
Mailing Address - Phone:904-376-4083
Mailing Address - Fax:904-391-5075
Practice Address - Street 1:841 PRUDENTIAL DR STE 280
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8350
Practice Address - Country:US
Practice Address - Phone:904-202-8550
Practice Address - Fax:904-393-7808
Is Sole Proprietor?:No
Enumeration Date:2011-08-22
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11012933363LP0200X
FLAPRN11012933363LP0200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1194005199Medicaid
NC7005620Medicaid
VAC06141Medicare PIN