Provider Demographics
NPI:1669119590
Name:LEWIS, SARA NICOLE (NP)
Entity type:Individual
Prefix:
First Name:SARA
Middle Name:NICOLE
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 1:2455 S PINE BAR PL
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:ID
Mailing Address - Zip Code:83642-7497
Mailing Address - Country:US
Mailing Address - Phone:208-860-3386
Mailing Address - Fax:
Practice Address - Street 1:1660 S WOODSAGE AVE BLDG A
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:ID
Practice Address - Zip Code:83642-7670
Practice Address - Country:US
Practice Address - Phone:208-860-3386
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-12
Last Update Date:2022-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDF04220073363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily