Healthcare Provider Details

I. General information

NPI: 1568380525
Provider Name (Legal Business Name): SHERISE LEWIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2026
Last Update Date: 07/08/2026
Certification Date: 07/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 BROADRICK DR
DALTON GA
30720-2503
US

IV. Provider business mailing address

401 MATERA DR NW
CARTERSVILLE GA
30120-3305
US

V. Phone/Fax

Practice location:
  • Phone: 212-734-6621
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number290283
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: