Provider Demographics
NPI:1609695766
Name:BROWN, RENA NICOLE
Entity type:Individual
Prefix:MS
First Name:RENA
Middle Name:NICOLE
Last Name:BROWN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 SOUTH AVE APT F5
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30297-3905
Mailing Address - Country:US
Mailing Address - Phone:404-857-5091
Mailing Address - Fax:
Practice Address - Street 1:1120 SOUTH AVE APT F5
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:GA
Practice Address - Zip Code:30297-3905
Practice Address - Country:US
Practice Address - Phone:404-857-5091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-07
Last Update Date:2024-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT009225225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist