Provider Demographics
NPI:1891074266
Name:BROWN, SANDRA BERNICE
Entity type:Individual
Prefix:
First Name:SANDRA
Middle Name:BERNICE
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 1:2131 N MERIDIAN RD
Mailing Address - Street 2:APT 144
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32303-5072
Mailing Address - Country:US
Mailing Address - Phone:850-573-4069
Mailing Address - Fax:
Practice Address - Street 1:2131 N MERIDIAN RD
Practice Address - Street 2:APT 144
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32303-5072
Practice Address - Country:US
Practice Address - Phone:850-573-4069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-16
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL674492396372500000X, 372600000X, 374U00000X, 376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion
No374U00000XNursing Service Related ProvidersHome Health Aide
No376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL674492396Medicaid