Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1700X | Ocularist |
NPI | 1811505795 |
---|---|
Provider Name | Kylie Brown |
First Address | Tempe, AZ 85282-3942 |
Second Address | Tempe, AZ 85282-3942 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 16/07/2020 |
Last Update Date | 16/07/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
374205 | (05) | AZ |