Provider Demographics
NPI:1275359663
Name:LEWIS, AMANDA JEAN
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JEAN
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 1:2104 WINTERSTEEN RUN RD
Mailing Address - Street 2:
Mailing Address - City:BLUE CREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45616-9735
Mailing Address - Country:US
Mailing Address - Phone:937-544-0203
Mailing Address - Fax:
Practice Address - Street 1:2762 WINTERSTEEN RUN RD
Practice Address - Street 2:
Practice Address - City:BLUE CREEK
Practice Address - State:OH
Practice Address - Zip Code:45616-9601
Practice Address - Country:US
Practice Address - Phone:937-544-0203
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-02
Last Update Date:2025-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH77156026172V00000X, 374U00000X, 3747P1801X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No172V00000XOther Service ProvidersCommunity Health Worker
No374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH3747P1801XMedicaid
OH1275359663Medicaid