Basic Information
| Provider Information | |||||||||
| NPI: | 1659403996 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | JACQUELINE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN,MSN, FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 BARNES AVE | ||||||||
| Address2: | |||||||||
| City: | LA JUNTA | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810502138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7163845446 | ||||||||
| FaxNumber: | 7193845672 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 KENDALL DR | ||||||||
| Address2: | |||||||||
| City: | LAMAR | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810523901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7163669154 | ||||||||
| FaxNumber: | 7193367453 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2007 | ||||||||
| LastUpdateDate: | 09/25/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WA2000X | 72910 | CO | Y | Nursing Service Providers | Registered Nurse | Administrator |
ID Information
| ID | Type | State | Issuer | Description | 07729106 | 05 | CO | MEDICAID |