Provider Demographics
NPI:1699908384
Name:BROWN, CAROLYN L
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:L
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 1:12203 ABERDEEN ST NE
Mailing Address - Street 2:SUITE 120
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-5174
Mailing Address - Country:US
Mailing Address - Phone:763-639-3595
Mailing Address - Fax:
Practice Address - Street 1:12203 ABERDEEN ST NE
Practice Address - Street 2:SUITE 120
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-5174
Practice Address - Country:US
Practice Address - Phone:763-639-3595
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-27
Last Update Date:2010-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1400208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice