Healthcare Provider Details

I. General information

NPI: 1285699934
Provider Name (Legal Business Name): JERRY MADISON LEWTER RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2006
Last Update Date: 03/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3726 ASHFORD DUNWOODY RD NE APT N
ATLANTA GA
30319-1873
US

IV. Provider business mailing address

3726 ASHFORD DUNWOODY RD NE APT N
ATLANTA GA
30319-1873
US

V. Phone/Fax

Practice location:
  • Phone: 678-404-2343
  • Fax:
Mailing address:
  • Phone: 678-404-2343
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License NumberRN158379
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN158379
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN158379
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberRN158379
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License NumberRN158379
License Number StateGA
# 6
Primary TaxonomyN
Taxonomy Code163WH0500X
TaxonomyHemodialysis Registered Nurse
License NumberRN158379
License Number StateGA
# 7
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License NumberRN158379
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: