Provider Demographics
NPI:1669743241
Name:LEWIS, LAQUITA DANIELLE (ACNP)
Entity type:Individual
Prefix:MS
First Name:LAQUITA
Middle Name:DANIELLE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:ACNP
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Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:C B 8054
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-362-6973
Mailing Address - Fax:314-362-1185
Practice Address - Street 1:1 BARNES JEWISH HOSPITAL PLZ
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1003
Practice Address - Country:US
Practice Address - Phone:314-362-6973
Practice Address - Fax:314-362-1185
Is Sole Proprietor?:No
Enumeration Date:2012-01-13
Last Update Date:2013-10-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2012005800364SA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO101740097Medicaid
IL$$$$$$$$$001Medicaid
MO101740097Medicaid