Basic Information
| Provider Information | |||||||||
| NPI: | 1063882280 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | AUDRA | ||||||||
| MiddleName: | BLYE | ||||||||
| NamePrefix: | |||||||||
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| Credential: | NP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BUTLER | ||||||||
| OtherFirstName: | AUDRA | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 100 TRACE CV | ||||||||
| Address2: | |||||||||
| City: | SENATOBIA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386684180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9012400438 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2714 UNION EXTD | ||||||||
| Address2: | SUITE 150 | ||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381124431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017250872 | ||||||||
| FaxNumber: | 9012786934 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2015 | ||||||||
| LastUpdateDate: | 07/25/2018 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R881185 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.