Provider Demographics
NPI:1689358897
Name:LEWIS, MIA
Entity Type:Individual
Prefix:
First Name:MIA
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:PO BOX 5414
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72303-5414
Mailing Address - Country:US
Mailing Address - Phone:870-636-1344
Mailing Address - Fax:
Practice Address - Street 1:9900 LAKE FOREST BLVD STE F
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70127-2609
Practice Address - Country:US
Practice Address - Phone:504-620-0500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-09
Last Update Date:2023-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program