Provider Demographics
NPI:1861462624
Name:LEWIS, DORNEL J (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:DORNEL
Middle Name:J
Last Name:LEWIS
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 SUMMIT HEIGHTS CT
Mailing Address - Street 2:
Mailing Address - City:ELLENWOOD
Mailing Address - State:GA
Mailing Address - Zip Code:30294-2973
Mailing Address - Country:US
Mailing Address - Phone:404-254-8250
Mailing Address - Fax:
Practice Address - Street 1:2808 E ATLANTA RD
Practice Address - Street 2:SUITE 344
Practice Address - City:ELLENWOOD
Practice Address - State:GA
Practice Address - Zip Code:30294-2780
Practice Address - Country:US
Practice Address - Phone:404-434-0401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN248615163W00000X, 163WR0006X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA201533051OtherEIN