Provider Demographics
NPI:1669456018
Name:MOURILLON BROWN, NICOLE ELOISE (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:ELOISE
Last Name:MOURILLON BROWN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:NICOLE
Other - Middle Name:E
Other - Last Name:MOURILLON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:200 CORPORATE BLVD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-3870
Mailing Address - Country:US
Mailing Address - Phone:800-893-9698
Mailing Address - Fax:
Practice Address - Street 1:901 MACARTHUR BLVD
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2901
Practice Address - Country:US
Practice Address - Phone:219-836-4511
Practice Address - Fax:219-836-7048
Is Sole Proprietor?:No
Enumeration Date:2005-11-30
Last Update Date:2022-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA321600207P00000X
IL036108186207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000531125OtherANTHEM BCBS
INP00408759OtherRAILROAD
IL036108186Medicaid
IN200872480Medicaid
IL90001082OtherBCBS