Basic Information
| Provider Information | |||||||||
| NPI: | 1649332362 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | JUANA | ||||||||
| MiddleName: | MARISSA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RD, LD, MPH, CDE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4205 BELFORT RD STE 4015 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322163623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042965691 | ||||||||
| FaxNumber: | 9044506401 | ||||||||
| Practice Location | |||||||||
| Address1: | 4203 BELFORT RD STE 315 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9044506860 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/16/2006 | ||||||||
| LastUpdateDate: | 08/23/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | ND3644 | FL | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | EV261Z | 01 | FL | MEDICARE | OTHER |