1043201056 NPI number — DIANA LOUISE LEWIS N.P.

Table of content: LEATRICE DEPP (NPI 1568249563)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043201056 NPI number — DIANA LOUISE LEWIS N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEWIS
Provider First Name:
DIANA
Provider Middle Name:
LOUISE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
N.P.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEWIS
Provider Other First Name:
DIANA
Provider Other Middle Name:
LOUISE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
N.P.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1043201056
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/27/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
NM HIGHWAY 120 @MILE MARKER 12.5, SOUTH SIDE OF HIGHWAY
Provider Second Line Business Mailing Address:
P.O. BOX 203
Provider Business Mailing Address City Name:
OCATE
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87734
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-666-2475
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
NM STATE HIGHWAY 120,
Provider Second Line Business Practice Location Address:
MILE MARKER 12.5
Provider Business Practice Location Address City Name:
OCATE
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87734
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-666-2475
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/31/2005

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:  R24775 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: NM400019 . This is a "INDIVIDUAL PTAN" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: NMB2163 . This is a "GROUP PTAN NMB2163" identifier , issued by the state of ( NM ) . This identifiers is of the category "OTHER".
  • Identifier: 22002570 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".
  • Identifier: 41903765 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




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