Provider Demographics
NPI:1174028328
Name:LEWIS, DANIKA KRISTAN (LMT)
Entity Type:Individual
Prefix:
First Name:DANIKA
Middle Name:KRISTAN
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2305 N EAGLE CREEK LN
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-6819
Mailing Address - Country:US
Mailing Address - Phone:208-761-0090
Mailing Address - Fax:
Practice Address - Street 1:2305 N EAGLE CREEK LN
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-6819
Practice Address - Country:US
Practice Address - Phone:208-761-0090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT103802225700000X
IDMAS-3301225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Multi-Specialty