Provider Demographics
NPI:1194473504
Name:BROWN, KERRY ALLEN
Entity Type:Individual
Prefix:
First Name:KERRY
Middle Name:ALLEN
Last Name:BROWN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7602 W POWHATAN AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33615-4147
Mailing Address - Country:US
Mailing Address - Phone:717-319-6068
Mailing Address - Fax:
Practice Address - Street 1:4100 W KENNEDY BLVD STE 312
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-2290
Practice Address - Country:US
Practice Address - Phone:813-667-0988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-15
Last Update Date:2022-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA882222225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty