Provider Demographics
NPI:1710346861
Name:BROWN, DOROTHY (LICENSE)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:LICENSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3732 N BIBO RD
Mailing Address - Street 2:
Mailing Address - City:GOLDEN VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86413-8586
Mailing Address - Country:US
Mailing Address - Phone:928-565-3179
Mailing Address - Fax:928-565-7986
Practice Address - Street 1:3732 N BIBO RD
Practice Address - Street 2:
Practice Address - City:GOLDEN VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86413-8586
Practice Address - Country:US
Practice Address - Phone:928-565-3179
Practice Address - Fax:928-565-7986
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-17
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL8993F310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZAL8993FOtherLICENSE