Provider Demographics
NPI:1023986759
Name:LEWIS, SHASTA
Entity type:Individual
Prefix:
First Name:SHASTA
Middle Name:
Last Name:LEWIS
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 41241
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36640-1241
Mailing Address - Country:US
Mailing Address - Phone:251-405-3677
Mailing Address - Fax:251-405-3233
Practice Address - Street 1:1200A SPRING HILL AVE
Practice Address - Street 2:
Practice Address - City:MOBILE
Practice Address - State:AL
Practice Address - Zip Code:36604-2718
Practice Address - Country:US
Practice Address - Phone:251-405-3677
Practice Address - Fax:251-405-3233
Is Sole Proprietor?:No
Enumeration Date:2025-10-24
Last Update Date:2025-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-204902163WR0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant