Provider Demographics
NPI:1700161072
Name:LEWIS, NIKIYA L
Entity Type:Individual
Prefix:
First Name:NIKIYA
Middle Name:L
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 BRAMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:STATESBORO
Mailing Address - State:GA
Mailing Address - Zip Code:30458-0851
Mailing Address - Country:US
Mailing Address - Phone:912-871-6206
Mailing Address - Fax:912-681-8558
Practice Address - Street 1:125B VICTORY DR
Practice Address - Street 2:
Practice Address - City:SWAINSBORO
Practice Address - State:GA
Practice Address - Zip Code:30401-3234
Practice Address - Country:US
Practice Address - Phone:478-419-1250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-18
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN184063363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003114992BMedicaid
1700161072OtherNPI
GARN184063NPOtherGA LICENSE