Basic Information
Provider Information | |||||||||
NPI: | 1053376368 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BROWN | ||||||||
FirstName: | ANGELICA | ||||||||
MiddleName: | S. | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 776351 | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606776351 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5025889490 | ||||||||
FaxNumber: | 5022725116 | ||||||||
Practice Location | |||||||||
Address1: | 1930 BISHOP LN | ||||||||
Address2: | SUITE 1600 | ||||||||
City: | LOUISVILLE | ||||||||
State: | KY | ||||||||
PostalCode: | 402181921 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5022725044 | ||||||||
FaxNumber: | 5022725121 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/19/2006 | ||||||||
LastUpdateDate: | 08/27/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/27/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 3002836 | KY | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 3002836 | KY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 000000107337 | 01 |   | ANTHEM - NCMA | OTHER | 008920 | 01 |   | SIHO - NCMA | OTHER | 000000642488 | 01 | KY | ANTHEM - HOUSE CALLS | OTHER | 2802676 | 01 | KY | CIGNA | OTHER | 2436183000 | 01 |   | PAD - NCMA | OTHER | 200251100 | 05 | IN |   | MEDICAID | 50015295 | 01 |   | PASSPORT - NCMA | OTHER | 50027323 | 01 | KY | PASSPORT & PASSPORT ADVANTAGE - HOUSE CALLS | OTHER | 7800413200 | 05 | KY |   | MEDICAID |