Healthcare Provider Details

I. General information

NPI: 1750787826
Provider Name (Legal Business Name): DEBORAH LEWIS M.S., R.D.N., L.D.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2014
Last Update Date: 11/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2599 KNEFF CEMETERY LN
CLAY CITY IL
62824-2232
US

IV. Provider business mailing address

2599 KNEFF CEMETERY LN
CLAY CITY IL
62824-2232
US

V. Phone/Fax

Practice location:
  • Phone: 618-322-4545
  • Fax:
Mailing address:
  • Phone: 618-322-4545
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164002036
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: