Healthcare Provider Details

I. General information

NPI: 1073649059
Provider Name (Legal Business Name): SUSAN G. LEWIS R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17929 GOTTSCHALK AVE
HOMEWOOD IL
60430-1709
US

IV. Provider business mailing address

17314 KEDZIE AVE
HAZEL CREST IL
60429-1619
US

V. Phone/Fax

Practice location:
  • Phone: 708-206-6155
  • Fax:
Mailing address:
  • Phone: 708-335-0020
  • Fax: 708-335-0022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: