Basic Information
| Provider Information | |||||||||
| NPI: | 1912582982 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | KAILA | ||||||||
| MiddleName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 617 FRANKLIN AVE | ||||||||
| Address2: | |||||||||
| City: | BERLIN | ||||||||
| State: | MD | ||||||||
| PostalCode: | 218111358 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3022127091 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7090 SAMUEL MORSE DR | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210463442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8883445977 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2021 | ||||||||
| LastUpdateDate: | 03/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/21/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | N | 106S00000X | RBT-21-158992 | MD | Y |
ID Information
| ID | Type | State | Issuer | Description | 523411500 | 05 | MD | MEDICAID |