Provider Demographics
NPI:1639660046
Name:LEWIS, INGRID (FNP)
Entity type:Individual
Prefix:
First Name:INGRID
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20831 RIDGEMONT RD
Mailing Address - Street 2:
Mailing Address - City:HARPER WOODS
Mailing Address - State:MI
Mailing Address - Zip Code:48225-1137
Mailing Address - Country:US
Mailing Address - Phone:313-930-0258
Mailing Address - Fax:
Practice Address - Street 1:12866 FORT ST
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-1060
Practice Address - Country:US
Practice Address - Phone:734-720-7920
Practice Address - Fax:734-720-7965
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-21
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704231587163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse