Healthcare Provider Details

I. General information

NPI: 1346179199
Provider Name (Legal Business Name): ILLEANA BROWN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2026
Last Update Date: 05/18/2026
Certification Date: 05/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

422 1ST AVE W
BENA MN
56626-1022
US

IV. Provider business mailing address

422 1ST AVE W
BENA MN
56626-1022
US

V. Phone/Fax

Practice location:
  • Phone: 218-821-6429
  • Fax:
Mailing address:
  • Phone: 218-821-6429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: