Provider Demographics
NPI:1265202238
Name:LEWIS, MARCIA L (RN)
Entity type:Individual
Prefix:
First Name:MARCIA
Middle Name:L
Last Name:LEWIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 VALLEYBROOK DR
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:GA
Mailing Address - Zip Code:30606-2466
Mailing Address - Country:US
Mailing Address - Phone:706-352-7941
Mailing Address - Fax:
Practice Address - Street 1:3021 ATLANTA HGHWAY
Practice Address - Street 2:
Practice Address - City:ATHENS
Practice Address - State:GA
Practice Address - Zip Code:30606-2644
Practice Address - Country:US
Practice Address - Phone:706-352-0911
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-02
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAKN-000389133N00000X
GARN232156163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No133N00000XDietary & Nutritional Service ProvidersNutritionist