Provider Demographics
NPI:1205912946
Name:LEWIS, ROSELINE KAGONYA (NP)
Entity type:Individual
Prefix:MRS
First Name:ROSELINE
Middle Name:KAGONYA
Last Name:LEWIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 S HOLLY AVE
Mailing Address - Street 2:
Mailing Address - City:COLLINS
Mailing Address - State:MS
Mailing Address - Zip Code:39428-3894
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 S HOLLY AVE
Practice Address - Street 2:
Practice Address - City:COLLINS
Practice Address - State:MS
Practice Address - Zip Code:39428-3894
Practice Address - Country:US
Practice Address - Phone:601-698-0238
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR784836207P00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00124929Medicaid
MS512G700003OtherMS MEDICARE - GROUP
MSP01236763Medicare PIN
P47925Medicare UPIN
MS00124929Medicaid
MS512G700003OtherMS MEDICARE - GROUP