Provider Demographics
NPI:1699768564
Name:LEWIS, VICKIE KARON (NP)
Entity type:Individual
Prefix:
First Name:VICKIE
Middle Name:KARON
Last Name:LEWIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:999 EXECUTIVE PARK BLVD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-4632
Mailing Address - Country:US
Mailing Address - Phone:423-224-3250
Mailing Address - Fax:423-224-3258
Practice Address - Street 1:1 MEDICAL PARK BLVD
Practice Address - Street 2:SUITE 3E
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7430
Practice Address - Country:US
Practice Address - Phone:423-844-5853
Practice Address - Fax:423-844-5588
Is Sole Proprietor?:No
Enumeration Date:2005-08-25
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5571363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3345430Medicaid
TN103I502830Medicare PIN
TNS65946Medicare UPIN
TN3345430Medicare ID - Type Unspecified
TN3345430Medicaid
TN10350I8168Medicare PIN