Provider Demographics
NPI:1295040483
Name:LEWIS, DIANA L (LMT)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:L
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:SKY
Other - Middle Name:
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:8146 DEER RUN WAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH WEBER
Mailing Address - State:UT
Mailing Address - Zip Code:84405-9432
Mailing Address - Country:US
Mailing Address - Phone:801-388-4377
Mailing Address - Fax:
Practice Address - Street 1:8146 DEER RUN WAY
Practice Address - Street 2:
Practice Address - City:SOUTH WEBER
Practice Address - State:UT
Practice Address - Zip Code:84405-9432
Practice Address - Country:US
Practice Address - Phone:801-388-4377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-11
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7509081-4701174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist