Provider Demographics
NPI:1982875639
Name:BROWN, MARY L
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:L
Last Name:BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:L
Other - Last Name:BROWN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN
Mailing Address - Street 1:N6768 GILBERT ST
Mailing Address - Street 2:
Mailing Address - City:ELKHORN
Mailing Address - State:WI
Mailing Address - Zip Code:53121-3511
Mailing Address - Country:US
Mailing Address - Phone:262-742-2882
Mailing Address - Fax:
Practice Address - Street 1:N6768 GILBERT ST
Practice Address - Street 2:
Practice Address - City:ELKHORN
Practice Address - State:WI
Practice Address - Zip Code:53121-3511
Practice Address - Country:US
Practice Address - Phone:262-742-2882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-20
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT57000-030163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35054800Medicaid