Provider Demographics
NPI:1942759543
Name:LEWIS, KELLY A (CNM)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:A
Last Name:LEWIS
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19714 E 10 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-1064
Mailing Address - Country:US
Mailing Address - Phone:248-909-1067
Mailing Address - Fax:
Practice Address - Street 1:19714 E 10 MILE RD
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1064
Practice Address - Country:US
Practice Address - Phone:586-779-9400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-25
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704271476176B00000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife