1548633183 NPI number — SHANIEQUA BROWN LADC

Table of content: SHANIEQUA BROWN LADC (NPI 1548633183)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1548633183 NPI number — SHANIEQUA BROWN LADC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROWN
Provider First Name:
SHANIEQUA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LADC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1548633183
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
153 BULL HILL LN
Provider Second Line Business Mailing Address:
SUITE 321
Provider Business Mailing Address City Name:
WEST HAVEN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06516-3928
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
153 BULL HILL LN
Provider Second Line Business Practice Location Address:
SUITE 321
Provider Business Practice Location Address City Name:
WEST HAVEN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06516-3928
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
999-999-9999
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/04/2015

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: 101YA0400X , with the licence number:  1170 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 008062470 . This is a "BROWN MEDICAID #" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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