Provider Demographics
NPI:1710587415
Name:BROWN, MARA S (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MARA
Middle Name:S
Last Name:BROWN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 561564
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80256-2560
Mailing Address - Country:US
Mailing Address - Phone:517-321-8568
Mailing Address - Fax:
Practice Address - Street 1:603 N WAVERLY RD STE 6
Practice Address - Street 2:
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48917-2800
Practice Address - Country:US
Practice Address - Phone:517-321-8568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704222901163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral PracticeGroup - Single Specialty