Provider Demographics
NPI:1821612912
Name:BROWN, PHAEDRA ROCHELLE
Entity Type:Individual
Prefix:
First Name:PHAEDRA
Middle Name:ROCHELLE
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 1:4670 BALD EAGLE WAY
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-7489
Mailing Address - Country:US
Mailing Address - Phone:470-707-3979
Mailing Address - Fax:
Practice Address - Street 1:4670 BALD EAGLE WAY
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-7489
Practice Address - Country:US
Practice Address - Phone:470-707-3979
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-03
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health