Provider Demographics
NPI:1548415193
Name:BROWN, WILLIE LEE
Entity Type:Individual
Prefix:MR
First Name:WILLIE
Middle Name:LEE
Last Name:BROWN
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:WILLIE
Other - Middle Name:LEE
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:600 CRAWFORD ST
Mailing Address - Street 2:SUITE P-D
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23704-3820
Mailing Address - Country:US
Mailing Address - Phone:757-393-0660
Mailing Address - Fax:757-393-0667
Practice Address - Street 1:600 CRAWFORD ST
Practice Address - Street 2:SUITE P-D
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23704-3820
Practice Address - Country:US
Practice Address - Phone:757-393-0660
Practice Address - Fax:757-393-0667
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-24
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA35674251E00000X
251G00000X, 253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251G00000XAgenciesHospice Care, Community Based
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA30-0260056Medicaid