Basic Information
| Provider Information | |||||||||
| NPI: | 1619108206 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEWIS-CARVOUR | ||||||||
| FirstName: | MELODI | ||||||||
| MiddleName: | LYNNE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1434 BROADRICK DR | ||||||||
| Address2: | |||||||||
| City: | DALTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307203009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7062785961 | ||||||||
| FaxNumber: | 7062750280 | ||||||||
| Practice Location | |||||||||
| Address1: | 170 CURTIS PKWY NE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | CALHOUN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 307012062 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068795770 | ||||||||
| FaxNumber: | 7066244336 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2009 | ||||||||
| LastUpdateDate: | 10/05/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 280 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA 2660 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | GRP4720 | 01 | GROUP # | OTHER |