Basic Information
| Provider Information | |||||||||
| NPI: | 1497990139 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | GWENDOLYN | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 207 S LEBANON ST | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460522544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654823630 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 207 S LEBANON ST | ||||||||
| Address2: | |||||||||
| City: | LEBANON | ||||||||
| State: | IN | ||||||||
| PostalCode: | 460522544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654823630 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2008 | ||||||||
| LastUpdateDate: | 10/12/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 71002816A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 000000621586 | 01 | IN | ANTHEM PIN | OTHER |