Healthcare Provider Details

I. General information

NPI: 1962893032
Provider Name (Legal Business Name): NICHOLAS BROWN CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2015
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

89 DOE VALLEY CV
JACKSON TN
38305-1988
US

IV. Provider business mailing address

89 DOE VALLEY CV
JACKSON TN
38305-1988
US

V. Phone/Fax

Practice location:
  • Phone: 205-641-1880
  • Fax:
Mailing address:
  • Phone: 205-641-1880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number105089
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: