Provider Demographics
NPI:1952723603
Name:BROWN, STACY (OT)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 18TH ST E
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-3648
Mailing Address - Country:US
Mailing Address - Phone:229-353-6124
Mailing Address - Fax:229-353-7722
Practice Address - Street 1:901 18TH ST E
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-3648
Practice Address - Country:US
Practice Address - Phone:229-353-6124
Practice Address - Fax:229-353-7722
Is Sole Proprietor?:No
Enumeration Date:2014-01-15
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOTA001175364SX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SX0106XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistOccupational Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAOTA001175OtherLICENSE NUMBER