=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912567546
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ADA BROWN-WALLS APN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/17/2019
-----------------------------------------------------
Last Update Date | 08/04/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6614 S INGLESIDE AVE APT 2S
-----------------------------------------------------
City | CHICAGO
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60637-4293
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 312-414-5642
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 50 S B B KING BLVD # 100
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38103-2626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-436-1381
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 209019417
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------