Provider Demographics
NPI:1013463611
Name:LEWIS, VIOLET STAR
Entity Type:Individual
Prefix:
First Name:VIOLET
Middle Name:STAR
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5025 S. JOHNNY RUN RD.
Mailing Address - Street 2:
Mailing Address - City:KINSMAN
Mailing Address - State:IL
Mailing Address - Zip Code:60437
Mailing Address - Country:US
Mailing Address - Phone:815-999-1855
Mailing Address - Fax:
Practice Address - Street 1:5025 S JOHNNY RUN RD
Practice Address - Street 2:
Practice Address - City:KINSMAN
Practice Address - State:IL
Practice Address - Zip Code:60437-4022
Practice Address - Country:US
Practice Address - Phone:815-999-1855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide