Provider Demographics
NPI:1366581084
Name:BROWN, SHANNAN DAVIS (LMT)
Entity type:Individual
Prefix:
First Name:SHANNAN
Middle Name:DAVIS
Last Name:BROWN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39229 KEAGHEY RD
Mailing Address - Street 2:
Mailing Address - City:PONCHATOULA
Mailing Address - State:LA
Mailing Address - Zip Code:70454-4641
Mailing Address - Country:US
Mailing Address - Phone:985-634-1687
Mailing Address - Fax:208-248-4170
Practice Address - Street 1:1232 S MORRISON BLVD
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-5702
Practice Address - Country:US
Practice Address - Phone:985-340-0044
Practice Address - Fax:208-248-4170
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LALA1640174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist