Provider Demographics
NPI:1568126068
Name:LEWIS, DALE ANDREW (NP-C)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:ANDREW
Last Name:LEWIS
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11700 TIOGA CT
Mailing Address - Street 2:
Mailing Address - City:JURUPA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91752-3061
Mailing Address - Country:US
Mailing Address - Phone:951-703-5057
Mailing Address - Fax:
Practice Address - Street 1:200 STONECREST BLVD # 155
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-6810
Practice Address - Country:US
Practice Address - Phone:951-703-5057
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-30
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN30354363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily