Provider Demographics
NPI:1801499843
Name:BROWN, LOLA ANNA I
Entity type:Individual
Prefix:
First Name:LOLA
Middle Name:ANNA
Last Name:BROWN
Suffix:I
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 DAKOTA AVE N
Mailing Address - Street 2:
Mailing Address - City:MADDOCK
Mailing Address - State:ND
Mailing Address - Zip Code:58348-7200
Mailing Address - Country:US
Mailing Address - Phone:701-351-1594
Mailing Address - Fax:
Practice Address - Street 1:122 DAKOTA AVE N
Practice Address - Street 2:
Practice Address - City:MADDOCK
Practice Address - State:ND
Practice Address - Zip Code:58348-7200
Practice Address - Country:US
Practice Address - Phone:701-351-1594
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1451575251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1451575Medicaid