Healthcare Provider Details

I. General information

NPI: 1245098755
Provider Name (Legal Business Name): JESSICA ANNE LEWIS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/08/2024
Last Update Date: 12/27/2024
Certification Date: 12/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 6TH ST
LEWISTON ID
83501
US

IV. Provider business mailing address

415 6TH STREET ATTN: PHYSICIAN SERVICES
LEWISTON ID
83501-2434
US

V. Phone/Fax

Practice location:
  • Phone: 208-750-7445
  • Fax: 208-750-7395
Mailing address:
  • Phone: 208-750-7462
  • Fax: 208-750-7467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number35472
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number78877
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: