Healthcare Provider Details

I. General information

NPI: 1013463611
Provider Name (Legal Business Name): VIOLET STAR LEWIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 09/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5025 S JOHNNY RUN RD
KINSMAN IL
60437-4022
US

IV. Provider business mailing address

5025 S. JOHNNY RUN RD.
KINSMAN IL
60437
US

V. Phone/Fax

Practice location:
  • Phone: 815-999-1855
  • Fax:
Mailing address:
  • Phone: 815-999-1855
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code376K00000X
TaxonomyNurse's Aide
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: