Provider Demographics
NPI:1275175218
Name:BROWN, EBONY S
Entity Type:Individual
Prefix:
First Name:EBONY
Middle Name:S
Last Name:BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1508 MARTIN LUTHER KING JR DR
Mailing Address - Street 2:
Mailing Address - City:TYLERTOWN
Mailing Address - State:MS
Mailing Address - Zip Code:39667-2636
Mailing Address - Country:US
Mailing Address - Phone:769-456-4083
Mailing Address - Fax:
Practice Address - Street 1:604 MAIN ST
Practice Address - Street 2:
Practice Address - City:PURVIS
Practice Address - State:MS
Practice Address - Zip Code:39475-5421
Practice Address - Country:US
Practice Address - Phone:769-456-4083
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-10
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS251E00000X
251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health