1104176049 NPI number — JETUWAN M BROWN REGISTERED NURSE

Table of content: JETUWAN M BROWN REGISTERED NURSE (NPI 1104176049)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104176049 NPI number — JETUWAN M BROWN REGISTERED NURSE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROWN
Provider First Name:
JETUWAN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
REGISTERED NURSE
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MCGRUDER
Provider Other First Name:
JETUWAN
Provider Other Middle Name:
Y
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1104176049
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
103 HONOURS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MADISON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39110-6513
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-278-6710
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
115 AULENBROCK DR STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CANTON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39046-7061
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-278-6710
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/18/2012

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: 163W00000X , with the licence number:  R875060 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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