Provider Demographics
NPI:1700642923
Name:BROWN, MIARIESHA
Entity Type:Individual
Prefix:
First Name:MIARIESHA
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:PO BOX 502
Mailing Address - Street 2:
Mailing Address - City:BLUE ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60406-0502
Mailing Address - Country:US
Mailing Address - Phone:773-984-0616
Mailing Address - Fax:
Practice Address - Street 1:ILLINOIS BACK INSTITUTE 11528 W 183RD ST
Practice Address - Street 2:SUITE SE
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467
Practice Address - Country:US
Practice Address - Phone:708-310-6733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-26
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILF02240211363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily