MEDICARE: MRS. FONDA BREWER-WILLIAMS CERTIFIED HAIR LOSS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1744P3200X	Prosthetics Case Management	47-4191902	MI

General Provider Information

NPI Number	:	1275909681
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. FONDA BREWER-WILLIAMS CERTIFIED HAIR LOSS

Provider Business Mailing Address
First Line	:	4255 MAR MOOR DR
Second Line	:
City	:	LANSING
State	:	MI
Zip	:	48917-1615
Country	:	US
Telephone Number	:	517-410-2998
Fax Number	:

Provider Business Practice Location Address
First Line	:	4255 MAR MOOR DR
Second Line	:
City	:	LANSING
State	:	MI
Zip	:	48917-1615
Country	:	US
Telephone Number	:	517-410-2998
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/19/2015
Last Update Date	:	08/19/2015

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