Provider Demographics
NPI:1538601703
Name:LEWIS, REBECCA
Entity type:Individual
Prefix:
First Name:REBECCA
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 1:402 FOREST RUN DR
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025-2176
Mailing Address - Country:US
Mailing Address - Phone:314-397-7015
Mailing Address - Fax:
Practice Address - Street 1:402 FOREST RUN DR
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:MO
Practice Address - Zip Code:63025-2176
Practice Address - Country:US
Practice Address - Phone:314-397-7015
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-05
Last Update Date:2017-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013022209163W00000X
MO2017029825363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse