Provider Demographics
NPI:1154836625
Name:LEWIS, BEVERLY A
Entity Type:Individual
Prefix:
First Name:BEVERLY
Middle Name:A
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1058 E WORTHY ST STE B
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-4302
Mailing Address - Country:US
Mailing Address - Phone:225-258-7322
Mailing Address - Fax:225-450-3799
Practice Address - Street 1:1058 E WORTHY ST STE B
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-4302
Practice Address - Country:US
Practice Address - Phone:225-258-7322
Practice Address - Fax:225-450-3799
Is Sole Proprietor?:No
Enumeration Date:2017-12-06
Last Update Date:2017-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA13669815587Medicaid