Basic Information
| Provider Information | |||||||||
| NPI: | 1730357104 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEWIS | ||||||||
| FirstName: | NICHOLE | ||||||||
| MiddleName: | M | ||||||||
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| Mailing Information | |||||||||
| Address1: | 660 SOUTH EUCLID | ||||||||
| Address2: | CAMPUS BOX 8124 | ||||||||
| City: | ST. LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 63110 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147472066 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4921 PARKVIEW PL STE 12B | ||||||||
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| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631101032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3147472066 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/19/2008 | ||||||||
| LastUpdateDate: | 05/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 085003673 | IL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 2008003778 | MO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.