Provider Demographics
NPI:1467404152
Name:LEWIS, KRISTEN M (FNP)
Entity Type:Individual
Prefix:
First Name:KRISTEN
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 1:30 HARRISON ST
Mailing Address - Street 2:SUITE 250
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790
Mailing Address - Country:US
Mailing Address - Phone:607-770-8600
Mailing Address - Fax:607-770-0853
Practice Address - Street 1:30 HARRISON ST
Practice Address - Street 2:SUITE 250
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790
Practice Address - Country:US
Practice Address - Phone:607-770-8600
Practice Address - Fax:607-770-0853
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF332667363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01976214Medicaid
BB6814Medicare ID - Type Unspecified
NY01976214Medicaid