Provider Demographics
NPI:1700653722
Name:LEWIS, VANITA
Entity Type:Individual
Prefix:
First Name:VANITA
Middle Name:
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 1:5421 KNOLL CREEK DR APT J
Mailing Address - Street 2:
Mailing Address - City:HAZELWOOD
Mailing Address - State:MO
Mailing Address - Zip Code:63042-3711
Mailing Address - Country:US
Mailing Address - Phone:314-201-9975
Mailing Address - Fax:
Practice Address - Street 1:5421 KNOLL CREEK DR APT J
Practice Address - Street 2:
Practice Address - City:HAZELWOOD
Practice Address - State:MO
Practice Address - Zip Code:63042-3711
Practice Address - Country:US
Practice Address - Phone:314-201-9975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-08
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO261QP2300X374U00000X
MO251E00000X374U00000X
MO253Z00000X374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide