Provider Demographics
NPI:1215531579
Name:BROWN, SYREETA ELISA (LPN)
Entity type:Individual
Prefix:
First Name:SYREETA
Middle Name:ELISA
Last Name:BROWN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:SYREETA
Other - Middle Name:ELISA
Other - Last Name:WALTERS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPN
Mailing Address - Street 1:6457 GOLDENROD CT
Mailing Address - Street 2:
Mailing Address - City:HENRICO
Mailing Address - State:VA
Mailing Address - Zip Code:23231-5330
Mailing Address - Country:US
Mailing Address - Phone:804-386-5674
Mailing Address - Fax:
Practice Address - Street 1:6457 GOLDENROD CT
Practice Address - Street 2:
Practice Address - City:HENRICO
Practice Address - State:VA
Practice Address - Zip Code:23231-5330
Practice Address - Country:US
Practice Address - Phone:804-386-5674
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-27
Last Update Date:2020-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0002088225164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty