Provider Demographics
NPI:1043235526
Name:LEWIS, JOHNNIE MAE (CRNA)
Entity Type:Individual
Prefix:
First Name:JOHNNIE
Middle Name:MAE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:JOHNNIE
Other - Middle Name:MAE
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1600 LAKELAND HILLS BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805-3065
Mailing Address - Country:US
Mailing Address - Phone:863-680-7000
Mailing Address - Fax:866-264-8519
Practice Address - Street 1:1600 LAKELAND HILLS BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805-3019
Practice Address - Country:US
Practice Address - Phone:863-680-7000
Practice Address - Fax:866-264-8519
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN1801642367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL304174300Medicaid
FL304174300Medicaid