Basic Information
| Provider Information | |||||||||
| NPI: | 1942331566 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | ALEATHA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BROWN | ||||||||
| OtherFirstName: | ANGEL | ||||||||
| OtherMiddleName: | ALEATHA | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 751803 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282751803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3369938181 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 291 BROAD ST | ||||||||
| Address2: | |||||||||
| City: | KERNERSVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 272842932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3369938181 | ||||||||
| FaxNumber: | 3369969539 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 09/24/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 8867 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2010-01050 | NC | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 5916107 | 05 | NC | MEDICAID |