=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275175218
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EBONY S BROWN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/10/2019
-----------------------------------------------------
Last Update Date | 10/10/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 604 MAIN ST
-----------------------------------------------------
City | PURVIS
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39475-5421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 769-456-4083
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1508 MARTIN LUTHER KING JR DR
-----------------------------------------------------
City | TYLERTOWN
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39667-2636
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 769-456-4083
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------