Provider Demographics
NPI:1700419355
Name:BROWN, MARANDA GABRIELLE (ATC)
Entity Type:Individual
Prefix:
First Name:MARANDA
Middle Name:GABRIELLE
Last Name:BROWN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 LIELMANIS AVE
Mailing Address - Street 2:
Mailing Address - City:HURLBURT FIELD
Mailing Address - State:FL
Mailing Address - Zip Code:32544-5613
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:113 LIELMANIS AVE
Practice Address - Street 2:
Practice Address - City:HURLBURT FIELD
Practice Address - State:FL
Practice Address - Zip Code:32544-5613
Practice Address - Country:US
Practice Address - Phone:850-390-0535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-21
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLAT-53712081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine