Provider Demographics
NPI:1497990139
Name:BROWN, GWENDOLYN J (APN)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:J
Last Name:BROWN
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:207 S LEBANON ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-2544
Mailing Address - Country:US
Mailing Address - Phone:765-482-3630
Mailing Address - Fax:
Practice Address - Street 1:207 S LEBANON ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IN
Practice Address - Zip Code:46052-2544
Practice Address - Country:US
Practice Address - Phone:765-482-3630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-10
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71002816A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000621586OtherANTHEM PIN
IN000000621586OtherANTHEM PIN
IN267030TTTMedicare PIN