Provider Demographics
NPI:1295010080
Name:BROWN, LISA DEANN
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DEANN
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 1:642 S GAMBLE ST
Mailing Address - Street 2:
Mailing Address - City:SHELBY
Mailing Address - State:OH
Mailing Address - Zip Code:44875-1712
Mailing Address - Country:US
Mailing Address - Phone:419-571-5601
Mailing Address - Fax:
Practice Address - Street 1:642 S GAMBLE ST
Practice Address - Street 2:
Practice Address - City:SHELBY
Practice Address - State:OH
Practice Address - Zip Code:44875-1712
Practice Address - Country:US
Practice Address - Phone:419-571-5601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-12
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN.14615-M-IV164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse