Provider Demographics
NPI:1578515144
Name:BROWN, MALISSA RENE (NP)
Entity Type:Individual
Prefix:
First Name:MALISSA
Middle Name:RENE
Last Name:BROWN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:255 ENTERPRISE BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-6300
Mailing Address - Country:US
Mailing Address - Phone:864-454-1142
Mailing Address - Fax:864-454-1144
Practice Address - Street 1:200 PATEWOOD DR
Practice Address - Street 2:SUITE A14
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29615-3593
Practice Address - Country:US
Practice Address - Phone:864-454-2226
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-16
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC2449363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP0359Medicaid
SC57-6007863106OtherBCBS OF SC
SC57-6007863106OtherBCBS OF SC