Provider Demographics
NPI:1063271005
Name:LEWIS, TYESHA CIERRA
Entity type:Individual
Prefix:
First Name:TYESHA
Middle Name:CIERRA
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34633 CLARKSON DR E APT 64
Mailing Address - Street 2:
Mailing Address - City:FRASER
Mailing Address - State:MI
Mailing Address - Zip Code:48026-3502
Mailing Address - Country:US
Mailing Address - Phone:248-870-8986
Mailing Address - Fax:
Practice Address - Street 1:34633 CLARKSON DR E APT 64
Practice Address - Street 2:
Practice Address - City:FRASER
Practice Address - State:MI
Practice Address - Zip Code:48026-3502
Practice Address - Country:US
Practice Address - Phone:248-870-8986
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-13
Last Update Date:2024-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5340312Medicaid