Provider Demographics
NPI:1356841944
Name:BROWN, HEIDI DAVONNE (LPN, CMLD, CEO)
Entity Type:Individual
Prefix:
First Name:HEIDI
Middle Name:DAVONNE
Last Name:BROWN
Suffix:
Gender:F
Credentials:LPN, CMLD, CEO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2918 BONDS AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46628-1957
Mailing Address - Country:US
Mailing Address - Phone:866-350-6400
Mailing Address - Fax:
Practice Address - Street 1:2918 BONDS AVE
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46628-1957
Practice Address - Country:US
Practice Address - Phone:866-350-6400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-20
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN15D2213193247ZC0005X
IN27075427A164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty
No247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physicianGroup - Single Specialty