Provider Demographics
NPI:1215448089
Name:BROWN, TINA RENA
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:RENA
Last Name:BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:431 E MARTIN LUTHER KING JR BLVD
Mailing Address - Street 2:
Mailing Address - City:CHATTAHOOCHEE
Mailing Address - State:FL
Mailing Address - Zip Code:32324-2216
Mailing Address - Country:US
Mailing Address - Phone:850-509-7081
Mailing Address - Fax:
Practice Address - Street 1:431 E MARTIN LUTHER KING JR BLVD
Practice Address - Street 2:
Practice Address - City:CHATTAHOOCHEE
Practice Address - State:FL
Practice Address - Zip Code:32324-2216
Practice Address - Country:US
Practice Address - Phone:850-509-7081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-19
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care