Provider Demographics
NPI:1578301891
Name:BROWN, CICELY KINISHA (NP)
Entity type:Individual
Prefix:
First Name:CICELY
Middle Name:KINISHA
Last Name:BROWN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3676 TAMPA TRL SW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30331-5308
Mailing Address - Country:US
Mailing Address - Phone:678-662-2564
Mailing Address - Fax:
Practice Address - Street 1:805 LANIER AVE E
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30214-2204
Practice Address - Country:US
Practice Address - Phone:770-694-6349
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-19
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GANCO-000003363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health