Provider Demographics
NPI:1740735844
Name:LEWIS, KATIE LYNN (FNP)
Entity Type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:LYNN
Last Name:LEWIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:MS
Other - First Name:KATIE
Other - Middle Name:LYNN
Other - Last Name:CONLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:900 E BATTLEFIELD ST STE 124
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65807-5208
Mailing Address - Country:US
Mailing Address - Phone:417-986-1289
Mailing Address - Fax:
Practice Address - Street 1:900 E BATTLEFIELD ST STE 124
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-5208
Practice Address - Country:US
Practice Address - Phone:417-986-1289
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-18
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP88592085R0202X, 363L00000X, 363LF0000X
MO2017025483363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ184503Medicaid
AZ1841261989OtherGROUP NPI
AZP01731962OtherPROVIDER MEDICARE RAILROAD ID
AZZWCBBMOtherGROUP MEDICARE ID
AZ184503Medicaid
AZ005472OtherGROUP MEDICAID ID
AZ005472OtherGROUP MEDICAID ID