Provider Demographics
NPI:1790918910
Name:BROWN, DIANE MICHELLE (BS,MS, NHA)
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:MICHELLE
Last Name:BROWN
Suffix:
Gender:F
Credentials:BS,MS, NHA
Other - Prefix:
Other - First Name:DIANE
Other - Middle Name:MICHELLE
Other - Last Name:HICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BS,MS
Mailing Address - Street 1:109 SEBASTIAN DRIVE
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305
Mailing Address - Country:US
Mailing Address - Phone:850-510-3457
Mailing Address - Fax:
Practice Address - Street 1:4543 COOPERS CREEK PL SE
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:GA
Practice Address - Zip Code:30082-4816
Practice Address - Country:US
Practice Address - Phone:404-916-6326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-04
Last Update Date:2024-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0493906103K00000X
311ZA0620X, 372600000X, 374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No372600000XNursing Service Related ProvidersAdult Companion
No374U00000XNursing Service Related ProvidersHome Health Aide