Basic Information
| Provider Information | |||||||||
| NPI: | 1184995102 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | GWENDOLYN | ||||||||
| MiddleName: | JEANETTE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 902 MCCALLIE AVE | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374032724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236644460 | ||||||||
| FaxNumber: | 4236485675 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 MEMORIAL DR | ||||||||
| Address2: | |||||||||
| City: | DALTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307202529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4236644460 | ||||||||
| FaxNumber: | 4236485675 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2012 | ||||||||
| LastUpdateDate: | 01/23/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LN0005X | RN120677 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal, Critical Care |
ID Information
| ID | Type | State | Issuer | Description | RN126077 | 01 | GA | LICENSE | OTHER |