Provider Demographics
NPI:1124424940
Name:SPENCE - BROWN, KEDIAN
Entity type:Individual
Prefix:
First Name:KEDIAN
Middle Name:
Last Name:SPENCE - 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 1:966 MONTGOMERY ST
Mailing Address - Street 2:1F
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11213-5869
Mailing Address - Country:US
Mailing Address - Phone:347-981-7493
Mailing Address - Fax:
Practice Address - Street 1:966 MONTGOMERY ST
Practice Address - Street 2:1F
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11213-5869
Practice Address - Country:US
Practice Address - Phone:347-981-7493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-05
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY320286164W00000X
NY760391-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No164W00000XNursing Service ProvidersLicensed Practical Nurse