Provider Demographics
NPI:1780937318
Name:LEWIS, KIMBERLY A
Entity type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:A
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KIM
Other - Middle Name:A
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5018 W FLYNN LN
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85301-3410
Mailing Address - Country:US
Mailing Address - Phone:623-826-4633
Mailing Address - Fax:
Practice Address - Street 1:5018 W FLYNN LN
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85301-3410
Practice Address - Country:US
Practice Address - Phone:623-826-4633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-19
Last Update Date:2012-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
372500000X, 372600000X
AZCNA999952457376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
No372500000XNursing Service Related ProvidersChore Provider
No372600000XNursing Service Related ProvidersAdult Companion