1326431552 NPI number — MRS. LISA HOLTZCLAW BROWN APRN

Table of content: MRS. LISA HOLTZCLAW BROWN APRN (NPI 1326431552)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326431552 NPI number — MRS. LISA HOLTZCLAW BROWN APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BROWN
Provider First Name:
LISA
Provider Middle Name:
HOLTZCLAW
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APRN
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:
1326431552
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/12/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1431 FALKIRK LN NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENNESAW
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30152-6701
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-770-9350
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
780 CANTON RD NE
Provider Second Line Business Practice Location Address:
SUITE 410
Provider Business Practice Location Address City Name:
MARIETTA
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30060-7241
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-370-0370
Provider Business Practice Location Address Fax Number:
678-370-0371
Provider Enumeration Date:
03/12/2015

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:  165268 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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