Healthcare Provider Details

I. General information

NPI: 1639510951
Provider Name (Legal Business Name): CARLA RENE' BROWN-JEFFERSON REGISTERED NURSE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2013
Last Update Date: 07/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5640 N 97TH ST
MILWAUKEE WI
53225-2502
US

IV. Provider business mailing address

4446 N 75TH ST
MILWAUKEE WI
53218-5432
US

V. Phone/Fax

Practice location:
  • Phone: 414-817-2936
  • Fax:
Mailing address:
  • Phone: 414-817-2936
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number107558-30
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number107558-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: