Provider Demographics
NPI:1285385740
Name:LEWIS, SHANDA
Entity type:Individual
Prefix:
First Name:SHANDA
Middle Name:
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 1:2020 W 154TH ST
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90249-4223
Mailing Address - Country:US
Mailing Address - Phone:310-433-7215
Mailing Address - Fax:
Practice Address - Street 1:2020 W 154TH ST
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90249-4223
Practice Address - Country:US
Practice Address - Phone:310-433-7215
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-15
Last Update Date:2022-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95019042363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner