Provider Demographics
NPI:1790841146
Name:LEWELLEN, ANNA MARIE (MPT)
Entity Type:Individual
Prefix:MRS
First Name:ANNA
Middle Name:MARIE
Last Name:LEWELLEN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6775 DUNNVILLE WAY
Mailing Address - Street 2:
Mailing Address - City:HOLLISTER
Mailing Address - State:CA
Mailing Address - Zip Code:95023-9241
Mailing Address - Country:US
Mailing Address - Phone:831-636-3392
Mailing Address - Fax:
Practice Address - Street 1:321 SAN FELIPE RD
Practice Address - Street 2:STE 16
Practice Address - City:HOLLISTER
Practice Address - State:CA
Practice Address - Zip Code:95023-3035
Practice Address - Country:US
Practice Address - Phone:831-636-3392
Practice Address - Fax:833-163-6339
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT21364225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT21364OtherSTATE LICENSE
CAPT21364OtherSTATE LICENSE