Provider Demographics
NPI:1760543276
Name:FULLER-BROWN, LINDA JEAN (MD)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:JEAN
Last Name:FULLER-BROWN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:JEAN
Other - Last Name:WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:7436 CHIPPING SPARROW ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89084-4808
Mailing Address - Country:US
Mailing Address - Phone:702-217-9904
Mailing Address - Fax:
Practice Address - Street 1:7436 CHIPPING SPARROW ST
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89084-4808
Practice Address - Country:US
Practice Address - Phone:702-217-9904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2016-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC509662084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
F50967Medicare UPIN
F50967Medicare UPIN
5J039Medicare ID - Type Unspecified