Provider Demographics
NPI:1275909681
Name:BREWER-WILLIAMS, FONDA (CERTIFIED HAIR LOSS)
Entity Type:Individual
Prefix:MRS
First Name:FONDA
Middle Name:
Last Name:BREWER-WILLIAMS
Suffix:
Gender:F
Credentials:CERTIFIED HAIR LOSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4255 MAR MOOR DR
Mailing Address - Street 2:
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48917-1615
Mailing Address - Country:US
Mailing Address - Phone:517-410-2998
Mailing Address - Fax:
Practice Address - Street 1:4255 MAR MOOR DR
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-1615
Practice Address - Country:US
Practice Address - Phone:517-410-2998
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-19
Last Update Date:2015-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI47-41919021744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management