Basic Information
| Provider Information | |||||||||
| NPI: | 1669118857 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BROWN | ||||||||
| FirstName: | GERVINE | ||||||||
| MiddleName: | LAVINA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP-BC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EVERETT | ||||||||
| OtherFirstName: | GERVINE | ||||||||
| OtherMiddleName: | LAVINA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 117 W PATERSON ST | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490072557 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693492641 | ||||||||
| FaxNumber: | 2694665522 | ||||||||
| Practice Location | |||||||||
| Address1: | 117 W PATERSON ST | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490072581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2693492641 | ||||||||
| FaxNumber: | 2694888977 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2022 | ||||||||
| LastUpdateDate: | 06/22/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/22/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 4704278151 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 163W00000X | 4704278151 | MI | N | Nursing Service Providers | Registered Nurse |
No ID Information.