Healthcare Provider Details

I. General information

NPI: 1730871195
Provider Name (Legal Business Name): SUZANNE BROWN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2023
Last Update Date: 05/24/2023
Certification Date: 05/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5447 MAPLE LN STE A
FAYETTEVILLE WV
25840-6872
US

IV. Provider business mailing address

PO BOX 145
MOUNT NEBO WV
26679-0145
US

V. Phone/Fax

Practice location:
  • Phone: 304-574-1141
  • Fax:
Mailing address:
  • Phone: 304-619-8153
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number50978
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: