Provider Demographics
NPI:1770206591
Name:LEWIS, EQUILLA RENA (NP)
Entity type:Individual
Prefix:
First Name:EQUILLA
Middle Name:RENA
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:PO BOX 746724
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6724
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:312-733-9730
Practice Address - Street 1:103 COUNTRY CLUB DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-7603
Practice Address - Country:US
Practice Address - Phone:910-400-7002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5017121363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily