Provider Demographics
NPI:1780942789
Name:LEWIS, KIMBERLY SUE (PT)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:SUE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 GERRI DR
Mailing Address - Street 2:
Mailing Address - City:NEWNAN
Mailing Address - State:GA
Mailing Address - Zip Code:30263-4291
Mailing Address - Country:US
Mailing Address - Phone:770-252-2586
Mailing Address - Fax:
Practice Address - Street 1:2280 HIGHWAY 29 N
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30265-1031
Practice Address - Country:US
Practice Address - Phone:770-253-8833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-26
Last Update Date:2012-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT006631310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility