Provider Demographics
NPI:1770116808
Name:BROWN, LISA JO (FNP-C)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:JO
Last Name:BROWN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4115 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90712-1043
Mailing Address - Country:US
Mailing Address - Phone:239-595-7011
Mailing Address - Fax:
Practice Address - Street 1:440 N MOUNTAIN AVE STE 103
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-5183
Practice Address - Country:US
Practice Address - Phone:888-777-1945
Practice Address - Fax:805-413-9099
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-17
Last Update Date:2022-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95013982208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty