Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 6787 | ID |
N | 225100000X | Physical Therapist | 9959 | AZ |
NPI | 1003163205 |
---|---|
Provider Name | Brittany Renae Brown |
First Address | Lake Havasu City, AZ 86403-3830 |
Second Address | Ammon, ID 83406-4718 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/08/2012 |
Last Update Date | 13/02/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
736884 | (05) | AZ |