Healthcare Provider Details

I. General information

NPI: 1649811183
Provider Name (Legal Business Name): LANIECE J BROWN ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2019
Last Update Date: 09/11/2025
Certification Date: 09/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CAMPUS BOX 2660
NORMAL IL
61790-2660
US

IV. Provider business mailing address

2000 N LINDEN ST APT K102
NORMAL IL
61761-5324
US

V. Phone/Fax

Practice location:
  • Phone: 309-438-2000
  • Fax:
Mailing address:
  • Phone: 908-721-2056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT9065
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number096.016140
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: