MEDICARE: MRS. ANNA MARIE LEWELLEN MPT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	PT21364	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PT21364	OTHER	CA	STATE LICENSE

General Provider Information

NPI Number	:	1790841146
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ANNA MARIE LEWELLEN MPT

Provider Business Mailing Address
First Line	:	6775 DUNNVILLE WAY
Second Line	:
City	:	HOLLISTER
State	:	CA
Zip	:	95023-9241
Country	:	US
Telephone Number	:	831-636-3392
Fax Number	:

Provider Business Practice Location Address
First Line	:	321 SAN FELIPE RD
Second Line	:	STE 16
City	:	HOLLISTER
State	:	CA
Zip	:	95023-3035
Country	:	US
Telephone Number	:	831-636-3392
Fax Number	:	833-163-6339

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/29/2006
Last Update Date	:	01/27/2016

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