Healthcare Provider Details

I. General information

NPI: 1881709038
Provider Name (Legal Business Name): SALLY LUCILLE BROWN P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2006
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46314 TIMINE WAY
PENDLETON OR
97801-9417
US

IV. Provider business mailing address

46314 TIMINE WAY
PENDLETON OR
97801-9417
US

V. Phone/Fax

Practice location:
  • Phone: 541-240-8548
  • Fax: 541-240-8750
Mailing address:
  • Phone: 541-240-8548
  • Fax: 541-240-8750

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60002097
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5173269-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: