Provider Demographics
NPI:1952972093
Name:BROWN, LYSAMARIE
Entity Type:Individual
Prefix:
First Name:LYSAMARIE
Middle Name:
Last Name:BROWN
Suffix:
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 1:142 REDMON RD
Mailing Address - Street 2:
Mailing Address - City:WARTBURG
Mailing Address - State:TN
Mailing Address - Zip Code:37887-4100
Mailing Address - Country:US
Mailing Address - Phone:865-806-6016
Mailing Address - Fax:
Practice Address - Street 1:142 REDMON RD
Practice Address - Street 2:
Practice Address - City:WARTBURG
Practice Address - State:TN
Practice Address - Zip Code:37887-4100
Practice Address - Country:US
Practice Address - Phone:865-806-6016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-09
Last Update Date:2021-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000073085164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty