Basic Information
Provider Information | |||||||||
NPI: | 1396292587 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEWIS | ||||||||
FirstName: | ANGELA | ||||||||
MiddleName: | GAIL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 505 N MAIN | ||||||||
Address2: |   | ||||||||
City: | ULYSSES | ||||||||
State: | KS | ||||||||
PostalCode: | 67880 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6203561261 | ||||||||
FaxNumber: | 6203565655 | ||||||||
Practice Location | |||||||||
Address1: | 101 MEADOW LN | ||||||||
Address2: |   | ||||||||
City: | CHANDLER | ||||||||
State: | OK | ||||||||
PostalCode: | 748348786 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4052582640 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/06/2016 | ||||||||
LastUpdateDate: | 07/13/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 86497 | OK | N |   | Nursing Service Providers | Registered Nurse |   | 363LP2300X | 5377741051 | KS | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No ID Information.