Provider Demographics
NPI:1679519573
Name:GRANT BROWN, LATAI EBRETTE (MD)
Entity type:Individual
Prefix:
First Name:LATAI
Middle Name:EBRETTE
Last Name:GRANT BROWN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LATAI
Other - Middle Name:EBRETTE
Other - Last Name:GRANT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1428 APPLE ORCHARD LN
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-6768
Mailing Address - Country:US
Mailing Address - Phone:901-484-3952
Mailing Address - Fax:678-623-5800
Practice Address - Street 1:1428 APPLE ORCHARD LN
Practice Address - Street 2:
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-6768
Practice Address - Country:US
Practice Address - Phone:901-484-3952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK425182084N0400X
TNMD00000393912084N0400X
CAC1652392084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01873878Medicaid
TNI51301Medicare UPIN