Healthcare Provider Details

I. General information

NPI: 1447078837
Provider Name (Legal Business Name): SHANTANA LEWIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2024
Last Update Date: 10/03/2024
Certification Date: 09/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6338 SW 70TH CIR
OCALA FL
34474-1913
US

IV. Provider business mailing address

6338 SW 70TH CIR
OCALA FL
34474-1913
US

V. Phone/Fax

Practice location:
  • Phone: 352-207-6646
  • Fax:
Mailing address:
  • Phone: 352-207-6646
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number11035643
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number11035643
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: