Provider Demographics
NPI:1194052365
Name:LEWIS, HAZEL IRENE (RD)
Entity type:Individual
Prefix:MRS
First Name:HAZEL
Middle Name:IRENE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 LOGAN AVE
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-1829
Mailing Address - Country:US
Mailing Address - Phone:765-474-6858
Mailing Address - Fax:
Practice Address - Street 1:1125 LOGAN AVE
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-1829
Practice Address - Country:US
Practice Address - Phone:765-474-6858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-09
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37000715A133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric