Provider Demographics
NPI:1760018345
Name:BROWN, KANICOLE
Entity Type:Individual
Prefix:
First Name:KANICOLE
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 1:100 MAPLE LN
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:VA
Mailing Address - Zip Code:23487-9525
Mailing Address - Country:US
Mailing Address - Phone:757-371-3522
Mailing Address - Fax:
Practice Address - Street 1:100 MAPLE LN
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:VA
Practice Address - Zip Code:23487-9525
Practice Address - Country:US
Practice Address - Phone:757-371-3522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-16
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
343900000X
VA343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)