Basic Information
| Provider Information | |||||||||
| NPI: | 1932405966 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | EVE-LYNN | ||||||||
| MiddleName: | PATRICE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9737 FLYING MANE LN | ||||||||
| Address2: | |||||||||
| City: | ALTA LOMA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917371616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6267102472 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 15004 INNOVATION DR | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921283491 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8589275527 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2011 | ||||||||
| LastUpdateDate: | 02/21/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | AT9332 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.