Healthcare Provider Details

I. General information

NPI: 1114978756
Provider Name (Legal Business Name): DONNA BROWDER GRACE P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MISS DONNA DENISE BROWDER

II. Dates (important events)

Enumeration Date: 05/15/2006
Last Update Date: 07/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 MILLIKEN LN
ST AUGUSTINE FL
32080-8425
US

IV. Provider business mailing address

40 MILLIKEN LN
ST AUGUSTINE FL
32080-8425
US

V. Phone/Fax

Practice location:
  • Phone: 404-630-3595
  • Fax: 404-630-3595
Mailing address:
  • Phone: 404-630-3595
  • Fax: 404-630-3595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT005235
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code2251N0400X
TaxonomyNeurology Physical Therapist
License NumberPT005235
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code2251P0200X
TaxonomyPediatric Physical Therapist
License NumberPT005235
License Number StateGA
# 4
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT28203
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: