Provider Demographics
NPI:1891411641
Name:LEWIS, LATIAHA NICHELLE (APRN)
Entity Type:Individual
Prefix:
First Name:LATIAHA
Middle Name:NICHELLE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:86 SUMMER HILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-5646
Mailing Address - Country:US
Mailing Address - Phone:860-710-3104
Mailing Address - Fax:
Practice Address - Street 1:INTERCOMMUNITY, INC
Practice Address - Street 2:281 MAIN STREET
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06118
Practice Address - Country:US
Practice Address - Phone:860-569-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-13
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT11062363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health