Provider Demographics
NPI:1619022985
Name:BROWN, LENNIS JR
Entity Type:Individual
Prefix:
First Name:LENNIS
Middle Name:
Last Name:BROWN
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11231 RED SPRUCE DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-7607
Mailing Address - Country:US
Mailing Address - Phone:704-535-8722
Mailing Address - Fax:704-535-2516
Practice Address - Street 1:11231 RED SPRUCE DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28215-7607
Practice Address - Country:US
Practice Address - Phone:704-535-8722
Practice Address - Fax:704-535-2516
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC3476374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6601561Medicaid