Provider Demographics
NPI:1255604336
Name:LEWIS, WENDY AUTUMN (KCSA)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:AUTUMN
Last Name:LEWIS
Suffix:
Gender:F
Credentials:KCSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12503 NORTHOLT CT
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-8472
Mailing Address - Country:US
Mailing Address - Phone:502-445-2533
Mailing Address - Fax:
Practice Address - Street 1:4001 KRESGE WAY STE 200
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4640
Practice Address - Country:US
Practice Address - Phone:502-895-1995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-20
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYSA233246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant