Provider Demographics
NPI:1467091470
Name:BROWN, AMBERLY
Entity Type:Individual
Prefix:
First Name:AMBERLY
Middle Name:
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 1:5271 LAKE RIDGE DR APT 3B
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-6919
Mailing Address - Country:US
Mailing Address - Phone:901-728-7780
Mailing Address - Fax:
Practice Address - Street 1:109 S DAVIS AVE STE 4
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:MS
Practice Address - Zip Code:38732-3447
Practice Address - Country:US
Practice Address - Phone:662-545-1637
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-23
Last Update Date:2020-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6744225200000X
MS6560225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant