Provider Demographics
NPI:1073794814
Name:BROWN, MARY ELLEN (FNP)
Entity type:Individual
Prefix:
First Name:MARY ELLEN
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 SOUTHPARK AVENUE
Mailing Address - Street 2:
Mailing Address - City:LACKAWANNA
Mailing Address - State:NY
Mailing Address - Zip Code:14218-1504
Mailing Address - Country:US
Mailing Address - Phone:716-822-2028
Mailing Address - Fax:716-822-2029
Practice Address - Street 1:2600 SOUTHPARK AVENUE
Practice Address - Street 2:
Practice Address - City:LACKAWANNA
Practice Address - State:NY
Practice Address - Zip Code:14218-1504
Practice Address - Country:US
Practice Address - Phone:716-822-2028
Practice Address - Fax:716-822-2029
Is Sole Proprietor?:No
Enumeration Date:2007-11-20
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF335096-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00028208101OtherUNIVERA
NY000529830001OtherBLUE CROSS
NY01075516Medicaid
NY9514408OtherINDEPENDENT HEALTH
NYA400147939Medicare PIN