Provider Demographics
NPI:1588641658
Name:LEWIS, SANDRA ELAINE (CNM)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:ELAINE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 W DALE ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50703-1901
Mailing Address - Country:US
Mailing Address - Phone:319-235-5050
Mailing Address - Fax:319-235-5107
Practice Address - Street 1:146 W DALE ST
Practice Address - Street 2:SUITE 102
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50703-1901
Practice Address - Country:US
Practice Address - Phone:319-235-5050
Practice Address - Fax:319-235-5107
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAB-094080176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0419200Medicaid
IA1419200Medicaid
IA2419200Medicaid
IA0419200Medicaid
IA2419200Medicaid