Healthcare Provider Details

I. General information

NPI: 1073548137
Provider Name (Legal Business Name): JACQUELINE E BROWN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JACQUELINE ELAINE BROWN RN

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 MORTEN AVE
PETERSBURG VA
23805-2749
US

IV. Provider business mailing address

23719 COX ROAD
PETERSBURG VA
23803-6878
US

V. Phone/Fax

Practice location:
  • Phone: 804-862-8004
  • Fax: 804-862-6158
Mailing address:
  • Phone: 804-861-9499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number0001104556
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: