Basic Information
| Provider Information | |||||||||
| NPI: | 1649789355 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | VIVIAN | ||||||||
| MiddleName: | LYNNETTE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | AVERYHEART | ||||||||
| OtherFirstName: | VIVIAN | ||||||||
| OtherMiddleName: | LYNNETTE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4095 AMERICAN WAY STE 1 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381188339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012719500 | ||||||||
| FaxNumber: | 8653420120 | ||||||||
| Practice Location | |||||||||
| Address1: | 4095 AMERICAN WAY STE 1 | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381188339 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012719500 | ||||||||
| FaxNumber: | 8653420120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2017 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | LPN54875 | TN | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.