Healthcare Provider Details

I. General information

NPI: 1295726248
Provider Name (Legal Business Name): MS. PENNY R BROWN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 01/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 N HENDERSON ST STE A
GALESBURG IL
61401-3596
US

IV. Provider business mailing address

430 N HENDERSON ST STE A
GALESBURG IL
61401-3596
US

V. Phone/Fax

Practice location:
  • Phone: 309-342-8676
  • Fax: 309-342-8676
Mailing address:
  • Phone: 309-342-8676
  • Fax: 309-342-8676

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code156FX1800X
TaxonomyOptician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: