Provider Demographics
NPI:1508696725
Name:BROWN, MAUNDRETTA MONIQUE
Entity type:Individual
Prefix:
First Name:MAUNDRETTA
Middle Name:MONIQUE
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 1:15904 LA SALLE BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48238-1483
Mailing Address - Country:US
Mailing Address - Phone:313-556-6809
Mailing Address - Fax:
Practice Address - Street 1:15904 LA SALLE BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238-1483
Practice Address - Country:US
Practice Address - Phone:313-556-6809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-02
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI362590609108343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)