Provider Demographics
NPI:1962695379
Name:LEWIS, MIRIAM (NP)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
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 1:19353 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-6302
Mailing Address - Country:US
Mailing Address - Phone:818-654-9736
Mailing Address - Fax:
Practice Address - Street 1:19353 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91335-6302
Practice Address - Country:US
Practice Address - Phone:310-869-6077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-20
Last Update Date:2019-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN587481363LX0001X, 363LX0001X
CA15958363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABI521ZMedicare PIN