Provider Demographics
NPI:1467863894
Name:LEWIS, BLANCHE (RN)
Entity Type:Individual
Prefix:
First Name:BLANCHE
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8826 MACKINAW ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48204-2372
Mailing Address - Country:US
Mailing Address - Phone:313-728-0351
Mailing Address - Fax:
Practice Address - Street 1:9605 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48204-2139
Practice Address - Country:US
Practice Address - Phone:313-834-5930
Practice Address - Fax:313-834-4541
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-20
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704174451163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)