Provider Demographics
NPI:1124449871
Name:LEWIS, VERLEEN
Entity type:Individual
Prefix:
First Name:VERLEEN
Middle Name:
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 1:90 GRAY AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-1065
Mailing Address - Country:US
Mailing Address - Phone:845-325-4367
Mailing Address - Fax:
Practice Address - Street 1:207 HALLOCK RD STE 201
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-3073
Practice Address - Country:US
Practice Address - Phone:631-689-8920
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-26
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY276198-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse