Provider Demographics
NPI:1396365763
Name:BROWN, SHERRY J
Entity Type:Individual
Prefix:MRS
First Name:SHERRY
Middle Name:J
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 1:3113 TOBIAS RD
Mailing Address - Street 2:
Mailing Address - City:CEDARVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:45314
Mailing Address - Country:US
Mailing Address - Phone:937-901-0789
Mailing Address - Fax:
Practice Address - Street 1:3113 TOBIAS RD
Practice Address - Street 2:
Practice Address - City:CEDARVILLE
Practice Address - State:OH
Practice Address - Zip Code:45314-9518
Practice Address - Country:US
Practice Address - Phone:937-901-0789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-25
Last Update Date:2020-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH511106374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH511106Medicaid