Provider Demographics
NPI:1528249984
Name:LEWIS, BRANDI NICOLE (LPN AAS)
Entity type:Individual
Prefix:
First Name:BRANDI
Middle Name:NICOLE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LPN AAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1048 16TH AVE S
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56301-5236
Mailing Address - Country:US
Mailing Address - Phone:320-980-7490
Mailing Address - Fax:
Practice Address - Street 1:1048 16TH AVE S
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-5236
Practice Address - Country:US
Practice Address - Phone:320-980-7490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-14
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL 062936-8164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse