Healthcare Provider Details

I. General information

NPI: 1548637382
Provider Name (Legal Business Name): TEGWYN LEWIS-PINE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/27/2015
Last Update Date: 08/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39500 LIBERTY ST
FREMONT CA
94538-2211
US

IV. Provider business mailing address

39500 LIBERTY ST
FREMONT CA
94538-2211
US

V. Phone/Fax

Practice location:
  • Phone: 510-770-8040
  • Fax:
Mailing address:
  • Phone: 510-770-8040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number95002877
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: