Provider Demographics
NPI:1720624372
Name:BROWN, NORDIAN SHANAE
Entity Type:Individual
Prefix:
First Name:NORDIAN
Middle Name:SHANAE
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 1:3814 SLEEPY HILL OAKS LOOP
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33810-3558
Mailing Address - Country:US
Mailing Address - Phone:850-567-7993
Mailing Address - Fax:
Practice Address - Street 1:200 S PARK RD STE 200
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-8541
Practice Address - Country:US
Practice Address - Phone:850-567-7993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-19
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN110045363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty