Provider Demographics
NPI:1871130690
Name:BROWN, TONYA HAYNES (SPECIALIST)
Entity type:Individual
Prefix:
First Name:TONYA
Middle Name:HAYNES
Last Name:BROWN
Suffix:
Gender:F
Credentials:SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:228 CAMBRIDGE LANE RD
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-4076
Mailing Address - Country:US
Mailing Address - Phone:803-309-0405
Mailing Address - Fax:
Practice Address - Street 1:1224 BROAD RIVER RD
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29210-7619
Practice Address - Country:US
Practice Address - Phone:803-798-0505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-01
Last Update Date:2019-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCRC342011744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty