Provider Demographics
NPI:1386090306
Name:LEWIS, ANGELA
Entity type:Individual
Prefix:
First Name:ANGELA
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 1:1360 S 5TH ST STE 280
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301-2446
Mailing Address - Country:US
Mailing Address - Phone:636-410-8220
Mailing Address - Fax:636-410-8228
Practice Address - Street 1:1360 S 5TH ST STE 280
Practice Address - Street 2:
Practice Address - City:SAINT CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301-2446
Practice Address - Country:US
Practice Address - Phone:636-410-8220
Practice Address - Fax:636-410-8228
Is Sole Proprietor?:No
Enumeration Date:2016-05-09
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOMO59178012163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0016584Medicaid