Provider Demographics
NPI:1588918122
Name:LEWIS, KAYLEE MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:KAYLEE
Middle Name:MARIE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KAYLEE
Other - Middle Name:MARIE
Other - Last Name:FARRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5801 KINGSFIELD DR
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-1479
Mailing Address - Country:US
Mailing Address - Phone:585-754-0202
Mailing Address - Fax:
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:313-916-3281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-05
Last Update Date:2018-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016201363A00000X
MI5601007727363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY016201OtherLICENSE
NY1104144OtherNCCPA