Provider Demographics
NPI:1164246948
Name:BROWN, MISTY DAWN
Entity type:Individual
Prefix:
First Name:MISTY
Middle Name:DAWN
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 1:2119 SERENITY LN
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:CA
Mailing Address - Zip Code:95503-6743
Mailing Address - Country:US
Mailing Address - Phone:707-684-1453
Mailing Address - Fax:
Practice Address - Street 1:2119 SERENITY LN
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:CA
Practice Address - Zip Code:95503-6743
Practice Address - Country:US
Practice Address - Phone:707-684-1453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-08
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD5554867172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty