Provider Demographics
NPI:1912478868
Name:BROWN, JOAN ICILDA
Entity Type:Individual
Prefix:MISS
First Name:JOAN
Middle Name:ICILDA
Last Name:BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JOAN
Other - Middle Name:ICILDA
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP-C
Mailing Address - Street 1:3341 MEADOVISTA DR
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-6638
Mailing Address - Country:US
Mailing Address - Phone:917-843-8386
Mailing Address - Fax:
Practice Address - Street 1:3341 MEADOVISTA DR
Practice Address - Street 2:
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294-6638
Practice Address - Country:US
Practice Address - Phone:917-843-8386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-17
Last Update Date:2018-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN177358163W00000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAF10181019OtherCERTIFICATION