Provider Demographics
NPI:1568124717
Name:LEWIS, LAGWEN
Entity Type:Individual
Prefix:
First Name:LAGWEN
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1513 LINE AVENUE
Mailing Address - Street 2:SUITE 225
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104
Mailing Address - Country:US
Mailing Address - Phone:318-754-3890
Mailing Address - Fax:318-658-9012
Practice Address - Street 1:1513 LINE AVENUE
Practice Address - Street 2:SUITE 225
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71104
Practice Address - Country:US
Practice Address - Phone:318-754-3890
Practice Address - Fax:318-658-9012
Is Sole Proprietor?:No
Enumeration Date:2021-10-05
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA065442163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse