1164793246 NPI number — MRS. AMY RENEE LEWIS R.N., AGPCNP-BC

Table of content: MRS. AMY RENEE LEWIS R.N., AGPCNP-BC (NPI 1164793246)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164793246 NPI number — MRS. AMY RENEE LEWIS R.N., AGPCNP-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEWIS
Provider First Name:
AMY
Provider Middle Name:
RENEE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
R.N., AGPCNP-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1164793246
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2800 E BROAD ST STE 517
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MANSFIELD
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76063-6417
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-592-3002
Provider Business Mailing Address Fax Number:
817-549-5151

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2800 E BROAD ST STE 517
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MANSFIELD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76063-6417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-592-3002
Provider Business Practice Location Address Fax Number:
817-549-5151
Provider Enumeration Date:
01/20/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2200X , with the licence number:  676199 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LA2200X , with the licence number: AP121311 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: TXB157975 . This is a "MEDICARE PTAN" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: V0190197 . This is a "TEXAS DEPARTMENT OF PUBLIC SAFETY (DPS) CONTROLLED SUBSTANCES REG." identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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