Provider Demographics
NPI:1942751680
Name:LEWIS, KIMBERLY (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4110 FLORIDA ST
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-3806
Mailing Address - Country:US
Mailing Address - Phone:601-498-4203
Mailing Address - Fax:
Practice Address - Street 1:801 HARDING BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70807-5326
Practice Address - Country:US
Practice Address - Phone:225-771-2317
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-18
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA3013762255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer