Provider Demographics
NPI:1649224023
Name:LEWIS, PHYLLIS B (ARNP)
Entity Type:Individual
Prefix:MS
First Name:PHYLLIS
Middle Name:B
Last Name:LEWIS
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 UNIVERSITY BLVD. NORTH
Mailing Address - Street 2:MC 75
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32211
Mailing Address - Country:US
Mailing Address - Phone:904-253-2062
Mailing Address - Fax:904-253-1942
Practice Address - Street 1:5190-9 TIMUQUANA ROAD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210
Practice Address - Country:US
Practice Address - Phone:904-253-1120
Practice Address - Fax:904-253-2514
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP608312363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL034949601Medicaid
FL0349496-01Medicaid
FL034949601Medicaid
FLS47099Medicare UPIN