Provider Demographics
NPI:1104943810
Name:LEWIS, JACQUELINE LENORE (RN)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:LENORE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1115
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27323-1115
Mailing Address - Country:US
Mailing Address - Phone:336-589-8197
Mailing Address - Fax:
Practice Address - Street 1:197 E AIKEN RD
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NC
Practice Address - Zip Code:27288-2201
Practice Address - Country:US
Practice Address - Phone:336-623-7715
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-079-056376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator