Healthcare Provider Details

I. General information

NPI: 1407197841
Provider Name (Legal Business Name): DORENDA LEWIS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2013
Last Update Date: 07/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4177 S ARCHER AVE
CHICAGO IL
60632-1849
US

IV. Provider business mailing address

3170 W 83RD PL
CHICAGO IL
60652-3423
US

V. Phone/Fax

Practice location:
  • Phone: 773-254-2222
  • Fax:
Mailing address:
  • Phone: 773-405-0294
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number209009219
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: