Provider Demographics
NPI:1639840200
Name:BROWN, LISA A
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
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 1:1144 BLUEBERRY HILL DR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44212-2522
Mailing Address - Country:US
Mailing Address - Phone:330-304-5088
Mailing Address - Fax:
Practice Address - Street 1:1144 BLUEBERRY HILL DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:OH
Practice Address - Zip Code:44212-2522
Practice Address - Country:US
Practice Address - Phone:330-304-5088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-23
Last Update Date:2021-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1313Medicaid