Provider Demographics
NPI:1285350413
Name:LEWIS, DIANNE (BSN, RN-BC)
Entity type:Individual
Prefix:MRS
First Name:DIANNE
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:BSN, RN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:663 OLD MOUNTAIN RD NW
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30152-3840
Mailing Address - Country:US
Mailing Address - Phone:770-224-1732
Mailing Address - Fax:
Practice Address - Street 1:450 NORTHSIDE CHEROKEE BLVD
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-8015
Practice Address - Country:US
Practice Address - Phone:770-313-7378
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-19
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN148704163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse