Provider Demographics
NPI:1568613370
Name:LEWIS-OUTLEY, PATRICE MICHELLE (FNP)
Entity Type:Individual
Prefix:
First Name:PATRICE
Middle Name:MICHELLE
Last Name:LEWIS-OUTLEY
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 1:403 MAIN STREET
Mailing Address - Street 2:P.O BOX 4251
Mailing Address - City:RUSTON
Mailing Address - State:LA
Mailing Address - Zip Code:71245
Mailing Address - Country:US
Mailing Address - Phone:318-243-3103
Mailing Address - Fax:
Practice Address - Street 1:CENTRAL AVENUE
Practice Address - Street 2:
Practice Address - City:GRAMBLING
Practice Address - State:LA
Practice Address - Zip Code:71245
Practice Address - Country:US
Practice Address - Phone:318-274-2288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-10
Last Update Date:2015-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN098033163W00000X
LAAP05587363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2304917Medicaid