1730585035 NPI number — SAMANTHA SHARRON LEWIS APRN

Table of content: SAMANTHA SHARRON LEWIS APRN (NPI 1730585035)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730585035 NPI number — SAMANTHA SHARRON LEWIS APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEWIS
Provider First Name:
SAMANTHA
Provider Middle Name:
SHARRON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1730585035
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
182 ROY CAMPBELL DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAZARD
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41701-9407
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-435-0888
Provider Business Mailing Address Fax Number:
606-435-0886

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
182 ROY CAMPBELL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HAZARD
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41701-9407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-435-0888
Provider Business Practice Location Address Fax Number:
606-435-0886
Provider Enumeration Date:
11/13/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  3009079 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 7100332490 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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