Provider Demographics
NPI:1164784161
Name:LEWIS, IOLY TABITA (PMHNP/ARNP)
Entity Type:Individual
Prefix:MS
First Name:IOLY
Middle Name:TABITA
Last Name:LEWIS
Suffix:
Gender:F
Credentials:PMHNP/ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 N CHELAN AVE
Mailing Address - Street 2:
Mailing Address - City:WENATCHEE
Mailing Address - State:WA
Mailing Address - Zip Code:98801-2028
Mailing Address - Country:US
Mailing Address - Phone:509-663-8711
Mailing Address - Fax:
Practice Address - Street 1:840 E HILL AVE
Practice Address - Street 2:
Practice Address - City:MOSES LAKE
Practice Address - State:WA
Practice Address - Zip Code:98837-2238
Practice Address - Country:US
Practice Address - Phone:509-663-8711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-14
Last Update Date:2019-05-20
Deactivation Date:2017-07-11
Deactivation Code:
Reactivation Date:2017-08-31
Provider Licenses
StateLicense IDTaxonomies
WAAP60785848363LP0808X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1164784167Medicaid
OR171037Medicaid
WAAP60785848OtherLIC