MEDICARE: MRS. ETHEL LOUISE BROWN BSN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	28132436A	IN
2	163WA0400X	Addiction (Substance Use Disorder) Registered Nurse	28113236A	IN

General Provider Information

NPI Number	:	1083806194
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ETHEL LOUISE BROWN BSN

Provider Business Mailing Address
First Line	:	3135 E 52ND ST
Second Line	:	UNIT B
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46205-1528
Country	:	US
Telephone Number	:	317-259-4996
Fax Number	:	317-259-4996

Provider Business Practice Location Address
First Line	:	3135 E 52ND ST
Second Line	:	UNIT B
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46205-1528
Country	:	US
Telephone Number	:	317-259-4996
Fax Number	:	317-259-4996

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/13/2007
Last Update Date	:	08/13/2007

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