Basic Information
| Provider Information | |||||||||
| NPI: | 1649879685 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | DEVRA | ||||||||
| MiddleName: | |||||||||
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| Credential: | LPN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 693 | ||||||||
| Address2: | |||||||||
| City: | WHITE SWAN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989520693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098742979 | ||||||||
| FaxNumber: | 5098742113 | ||||||||
| Practice Location | |||||||||
| Address1: | 80 BIRDSONG LANE | ||||||||
| Address2: | 401 FORT ROAD | ||||||||
| City: | WHITE SWAN | ||||||||
| State: | WA | ||||||||
| PostalCode: | 98952 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5098742979 | ||||||||
| FaxNumber: | 5098742113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2020 | ||||||||
| LastUpdateDate: | 10/21/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164W00000X | LP00050979 | WA | Y | Nursing Service Providers | Licensed Practical Nurse |
ID Information
| ID | Type | State | Issuer | Description | LP00050979 | 05 | WA | MEDICAID |