Healthcare Provider Details

I. General information

NPI: 1730633660
Provider Name (Legal Business Name): TASHANECA SHONTE LEWIS FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2016
Last Update Date: 08/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2805 HAMILTON MILL RD
BUFORD GA
30519-4110
US

IV. Provider business mailing address

3622 GREENWICH AVE
DULUTH GA
30096-6331
US

V. Phone/Fax

Practice location:
  • Phone: 678-541-0588
  • Fax: 678-541-0610
Mailing address:
  • Phone: 404-277-7286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN195801
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: