Provider Demographics
NPI:1366119042
Name:BROWN, TAVONNA M (LPN)
Entity type:Individual
Prefix:
First Name:TAVONNA
Middle Name:M
Last Name:BROWN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 KRATOVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERHEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11901-2906
Mailing Address - Country:US
Mailing Address - Phone:631-346-2608
Mailing Address - Fax:
Practice Address - Street 1:425 KRATOVILLE AVE
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2906
Practice Address - Country:US
Practice Address - Phone:631-346-2608
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY341940164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse