Provider Demographics
NPI:1194747584
Name:LEWIS, RICKY L (CRNP)
Entity type:Individual
Prefix:
First Name:RICKY
Middle Name:L
Last Name:LEWIS
Suffix:
Gender:M
Credentials:CRNP
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 398
Mailing Address - Street 2:
Mailing Address - City:ANDALUSIA
Mailing Address - State:AL
Mailing Address - Zip Code:36420-1207
Mailing Address - Country:US
Mailing Address - Phone:334-222-8421
Mailing Address - Fax:334-222-1248
Practice Address - Street 1:835 S THREE NOTCH ST
Practice Address - Street 2:
Practice Address - City:ANDALUSIA
Practice Address - State:AL
Practice Address - Zip Code:36420-5321
Practice Address - Country:US
Practice Address - Phone:334-222-8421
Practice Address - Fax:334-222-1248
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-061464363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALP69373Medicare UPIN