Basic Information
Provider Information | |||||||||
NPI: | 1932496072 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BROWN | ||||||||
FirstName: | LUCIE | ||||||||
MiddleName: | SHINALL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | ACNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | CALDWELL | ||||||||
OtherFirstName: | LUCIE | ||||||||
OtherMiddleName: | TERESA | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 55 WHITCHER ST NE STE 130 | ||||||||
Address2: |   | ||||||||
City: | MARIETTA | ||||||||
State: | GA | ||||||||
PostalCode: | 300601156 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7704280462 | ||||||||
FaxNumber: | 7704278001 | ||||||||
Practice Location | |||||||||
Address1: | 1825 MARTHA BERRY BLVD NW | ||||||||
Address2: |   | ||||||||
City: | ROME | ||||||||
State: | GA | ||||||||
PostalCode: | 301651625 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7062955331 | ||||||||
FaxNumber: | 7062918380 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/08/2011 | ||||||||
LastUpdateDate: | 05/17/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/17/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN169622 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | 003112882A | 05 | GA |   | MEDICAID |