Provider Demographics
NPI:1427154624
Name:LEWIS, PATRICIA (APRN)
Entity type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:
Other - Last Name:SHUTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13 MARILYN AVE
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32080-5345
Mailing Address - Country:US
Mailing Address - Phone:617-407-6527
Mailing Address - Fax:
Practice Address - Street 1:13 MARILYN AVE
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32080-5345
Practice Address - Country:US
Practice Address - Phone:617-407-6527
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2021-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA162923364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, AdultGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS47584Medicare UPIN
MANS0057Medicare ID - Type Unspecified