Provider Demographics
NPI:1831745504
Name:LEWIS, AUDREY KIM (PTA)
Entity type:Individual
Prefix:
First Name:AUDREY
Middle Name:KIM
Last Name:LEWIS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:AUDREY
Other - Middle Name:KIM
Other - Last Name:LEWIS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PTA
Mailing Address - Street 1:201 W 11TH ST
Mailing Address - Street 2:
Mailing Address - City:ELLINWOOD
Mailing Address - State:KS
Mailing Address - Zip Code:67526-9090
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:510 W 7TH ST
Practice Address - Street 2:
Practice Address - City:ELLINWOOD
Practice Address - State:KS
Practice Address - Zip Code:67526-1101
Practice Address - Country:US
Practice Address - Phone:620-564-2337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-17
Last Update Date:2019-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS14-01724225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant