Provider Demographics
NPI:1154148245
Name:LEWIS, MARY SHARDAE (LAC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:SHARDAE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:703 DAWN PL APT C
Mailing Address - Street 2:
Mailing Address - City:LANTANA
Mailing Address - State:FL
Mailing Address - Zip Code:33462-1615
Mailing Address - Country:US
Mailing Address - Phone:954-939-9196
Mailing Address - Fax:
Practice Address - Street 1:683 OLD MILL RD
Practice Address - Street 2:
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108-1326
Practice Address - Country:US
Practice Address - Phone:410-729-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-09-20
Last Update Date:2024-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU03140171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist