Provider Demographics
NPI:1457866477
Name:LEWIS, ANGELINA JAQUELINE
Entity Type:Individual
Prefix:MRS
First Name:ANGELINA
Middle Name:JAQUELINE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANGELINA
Other - Middle Name:JACQUELINA
Other - Last Name:VIVOLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:58 PARKWAY W
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10552-1141
Mailing Address - Country:US
Mailing Address - Phone:917-648-0072
Mailing Address - Fax:
Practice Address - Street 1:58 PARKWAY W
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10552-1141
Practice Address - Country:US
Practice Address - Phone:917-648-0072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-13
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist