1497835722 NPI number — GWENDOLYN CLARK BROWN FNP

Table of content: (NPI 1902091929)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497835722 NPI number — GWENDOLYN CLARK BROWN FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROWN
Provider First Name:
GWENDOLYN
Provider Middle Name:
CLARK
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1497835722
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/13/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 911230
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DALLAS
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75391-1230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
729-978-0009
Provider Business Mailing Address Fax Number:
972-234-0813

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10425 N CENTRAL EXPY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DALLAS
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75231-2208
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
214-361-2025
Provider Business Practice Location Address Fax Number:
214-361-2028
Provider Enumeration Date:
10/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  AP112485 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363L00000X , with the licence number: AP112485 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 165647203 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00125344 . This is a "RAILROAD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 8N4436 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 165647201 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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