Provider Demographics
NPI:1346731866
Name:LEWIS, WANDA M (FNP)
Entity Type:Individual
Prefix:
First Name:WANDA
Middle Name:M
Last Name:LEWIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10112 WINDY KNOLL CT
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48348-2182
Mailing Address - Country:US
Mailing Address - Phone:254-630-9421
Mailing Address - Fax:
Practice Address - Street 1:10112 WINDY KNOLL CT
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48348-2182
Practice Address - Country:US
Practice Address - Phone:254-630-9421
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-21
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704283277363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily