MEDICARE: BRIONCCA LEWIS RN

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	291U00000X	Clinical Medical Laboratory
2	163W00000X	Registered Nurse	2021026510	MO

General Provider Information

NPI Number	:	1982327615
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRIONCCA LEWIS RN

Provider Business Mailing Address
First Line	:	8520 ORLEANS LN
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76123-1637
Country	:	US
Telephone Number	:	618-977-4465
Fax Number	:

Provider Business Practice Location Address
First Line	:	3716 ROUND HILL RD APT 7
Second Line	:
City	:	SWANSEA
State	:	IL
Zip	:	62226-1226
Country	:	US
Telephone Number	:	618-977-4465
Fax Number	:

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

Provider Enumeration Date	:	09/19/2022
Last Update Date	:	09/19/2022

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