Provider Demographics
NPI:1811401466
Name:BROWN, MIGNONETTE L
Entity Type:Individual
Prefix:PROF
First Name:MIGNONETTE
Middle Name:L
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 1:5308 BERKSHIRE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-3206
Mailing Address - Country:US
Mailing Address - Phone:313-922-4775
Mailing Address - Fax:
Practice Address - Street 1:5308 BERKSHIRE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48224-3206
Practice Address - Country:US
Practice Address - Phone:313-922-4775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-18
Last Update Date:2017-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health