Provider Demographics
NPI:1962806364
Name:BROWN, DONNA MARIE
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:MARIE
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 1:125 WHITE DOGWOOD LN
Mailing Address - Street 2:
Mailing Address - City:POOLER
Mailing Address - State:GA
Mailing Address - Zip Code:31322-5006
Mailing Address - Country:US
Mailing Address - Phone:912-450-7367
Mailing Address - Fax:912-988-3149
Practice Address - Street 1:125 WHITE DOGWOOD LN
Practice Address - Street 2:
Practice Address - City:POOLER
Practice Address - State:GA
Practice Address - Zip Code:31322-5006
Practice Address - Country:US
Practice Address - Phone:912-450-7367
Practice Address - Fax:912-988-3149
Is Sole Proprietor?:No
Enumeration Date:2014-10-14
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP003005235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000789027BMedicaid