Provider Demographics
NPI:1164793246
Name:LEWIS, AMY RENEE (RN, ANP, GNP)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:RENEE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:RN, ANP, GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 E BROAD ST STE 504
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-6417
Mailing Address - Country:US
Mailing Address - Phone:682-242-8930
Mailing Address - Fax:817-453-8866
Practice Address - Street 1:2800 E BROAD ST
Practice Address - Street 2:SUITE 504
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-6409
Practice Address - Country:US
Practice Address - Phone:817-225-0410
Practice Address - Fax:817-453-8866
Is Sole Proprietor?:No
Enumeration Date:2012-01-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX676199363LA2200X
TXAP121311363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB157975OtherMEDICARE PTAN
TXV0190197OtherTEXAS DEPARTMENT OF PUBLIC SAFETY (DPS) CONTROLLED SUBSTANCES REG.
TXV0190197OtherTEXAS DEPARTMENT OF PUBLIC SAFETY (DPS) CONTROLLED SUBSTANCES REG.
TXTXB157975Medicare PIN