Provider Demographics
NPI:1003993627
Name:LEWELLEN, AMY MOONEY (DC)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:MOONEY
Last Name:LEWELLEN
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:MOONEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:50 COVE ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-2514
Mailing Address - Country:US
Mailing Address - Phone:207-828-8777
Mailing Address - Fax:207-828-8778
Practice Address - Street 1:50 COVE ST
Practice Address - Street 2:SUITE A
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2514
Practice Address - Country:US
Practice Address - Phone:207-828-8777
Practice Address - Fax:207-828-8778
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2015-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2455111N00000X
MECR1393111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1049468OtherASHN
MA4402698OtherACN
ME022182OtherANTHEM BCBS
MA2146577OtherFIRST HEALTH
MA351399OtherHPHC
ME1003993627OtherMEDCARE PTAN UX2254
MAY36775OtherBLUECROSS
MA0630793200OtherCIGNA
MA2503521OtherAETNA
MA351399OtherHPHC