Provider Demographics
NPI:1710421979
Name:BROWN, KEIANA
Entity Type:Individual
Prefix:
First Name:KEIANA
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 1:8152 VAL DEL RD
Mailing Address - Street 2:
Mailing Address - City:ADEL
Mailing Address - State:GA
Mailing Address - Zip Code:31620-6468
Mailing Address - Country:US
Mailing Address - Phone:904-415-9018
Mailing Address - Fax:
Practice Address - Street 1:8152 VAL DEL RD
Practice Address - Street 2:
Practice Address - City:ADEL
Practice Address - State:GA
Practice Address - Zip Code:31620-6468
Practice Address - Country:US
Practice Address - Phone:904-415-9018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-07
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor