Healthcare Provider Details

I. General information

NPI: 1932199932
Provider Name (Legal Business Name): LISA GAIL BREWER FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 10/21/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

576 JEFFERSON AVE
FORT EUSTIS VA
23604-1602
US

IV. Provider business mailing address

1551 WINTHROPE DR
NEWPORT NEWS VA
23602-9633
US

V. Phone/Fax

Practice location:
  • Phone: 757-314-7737
  • Fax:
Mailing address:
  • Phone: 757-874-6753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0024164308
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: