Basic Information
| Provider Information | |||||||||
| NPI: | 1740806488 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | JEANNE | ||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 3075 MYERS ST | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925035525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9519557829 | ||||||||
| FaxNumber: | 9513587829 | ||||||||
| Practice Location | |||||||||
| Address1: | 3075 MYERS ST | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925035525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9519557829 | ||||||||
| FaxNumber: | 9513587829 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2020 | ||||||||
| LastUpdateDate: | 06/18/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 175T00000X | Y |
No ID Information.