Provider Demographics
NPI:1891126322
Name:LEWIS, KATHY REGINA (ANP-BC)
Entity type:Individual
Prefix:MRS
First Name:KATHY
Middle Name:REGINA
Last Name:LEWIS
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:MRS
Other - First Name:KATHY
Other - Middle Name:REGINA
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:11447 JOSEPH CAMPAU ST
Mailing Address - Street 2:
Mailing Address - City:HAMTRAMCK
Mailing Address - State:MI
Mailing Address - Zip Code:48212-3040
Mailing Address - Country:US
Mailing Address - Phone:313-365-1362
Mailing Address - Fax:
Practice Address - Street 1:11447 JOSEPH CAMPAU ST
Practice Address - Street 2:
Practice Address - City:HAMTRAMCK
Practice Address - State:MI
Practice Address - Zip Code:48212-3040
Practice Address - Country:US
Practice Address - Phone:313-365-1362
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-10
Last Update Date:2014-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704191112363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health