Basic Information
| Provider Information | |||||||||
| NPI: | 1699768564 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | VICKIE | ||||||||
| MiddleName: | KARON | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 999 EXECUTIVE PARK BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376604632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232243250 | ||||||||
| FaxNumber: | 4232243258 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 MEDICAL PARK BLVD | ||||||||
| Address2: | SUITE 3E | ||||||||
| City: | BRISTOL | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376207430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238445853 | ||||||||
| FaxNumber: | 4238445588 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2005 | ||||||||
| LastUpdateDate: | 07/10/2012 | ||||||||
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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 | 363LF0000X | 5571 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 3345430 | 05 | TN | MEDICAID |