Provider Demographics
NPI:1932496072
Name:BROWN, LUCIE SHINALL (ACNP)
Entity Type:Individual
Prefix:
First Name:LUCIE
Middle Name:SHINALL
Last Name:BROWN
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:LUCIE
Other - Middle Name:TERESA
Other - Last Name:CALDWELL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:55 WHITCHER ST NE STE 130
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30060-1156
Mailing Address - Country:US
Mailing Address - Phone:770-428-0462
Mailing Address - Fax:770-427-8001
Practice Address - Street 1:1825 MARTHA BERRY BLVD NW
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:GA
Practice Address - Zip Code:30165-1625
Practice Address - Country:US
Practice Address - Phone:706-295-5331
Practice Address - Fax:706-291-8380
Is Sole Proprietor?:No
Enumeration Date:2011-07-08
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN169622363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003112882AMedicaid
GA003112882AMedicaid