1093349490 NPI number — AMY NICOLE HOMER-BROWN MBBS, MSOM, LAC

Table of content: AMY NICOLE HOMER-BROWN MBBS, MSOM, LAC (NPI 1093349490)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093349490 NPI number — AMY NICOLE HOMER-BROWN MBBS, MSOM, LAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HOMER-BROWN
Provider First Name:
AMY
Provider Middle Name:
NICOLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MBBS, MSOM, LAC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
HOMER
Provider Other First Name:
AMY
Provider Other Middle Name:
NICOLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MBBS, MSOM, LAC
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1093349490
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/25/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5885 SW MACADAM AVE APT 2204
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97239-3794
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-308-8676
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
630 SE POWELL BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97202-2623
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-308-8676
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/25/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171100000X , with the licence number:  AC196466 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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