Provider Demographics
NPI:1407816754
Name:LEWIS, MARIANNE D (APRN-BC)
Entity Type:Individual
Prefix:
First Name:MARIANNE
Middle Name:D
Last Name:LEWIS
Suffix:
Gender:F
Credentials:APRN-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9720 S TRYON ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28273-6578
Mailing Address - Country:US
Mailing Address - Phone:704-588-7362
Mailing Address - Fax:704-588-9127
Practice Address - Street 1:9720 S TRYON ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28273-6578
Practice Address - Country:US
Practice Address - Phone:704-588-7362
Practice Address - Fax:704-588-9127
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC81186363L00000X
SCAPN 422363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
D5856OtherMEDCOST
SCNP0419Medicaid
P13925Medicare UPIN