Provider Demographics
NPI:1982883914
Name:LEWIS, MONICA L (APN)
Entity Type:Individual
Prefix:
First Name:MONICA
Middle Name:L
Last Name:LEWIS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14701 S PULASKI
Mailing Address - Street 2:
Mailing Address - City:MIDLOTHIAN
Mailing Address - State:IL
Mailing Address - Zip Code:60445-3410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14701 PULASKI RD
Practice Address - Street 2:
Practice Address - City:MIDLOTHIAN
Practice Address - State:IL
Practice Address - Zip Code:60445-3410
Practice Address - Country:US
Practice Address - Phone:708-239-2150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-26
Last Update Date:2011-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-262920363LA2200X
IL041.262920363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL041-262920OtherSTATE LICENSE
ILK48712Medicare UPIN
IL041-262920OtherSTATE LICENSE