Healthcare Provider Details

I. General information

NPI: 1285232371
Provider Name (Legal Business Name): KASONDRA GLYNN LEWIS PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2020
Last Update Date: 12/16/2025
Certification Date: 12/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 S LAUREL RD STE 1
LONDON KY
40744-8300
US

IV. Provider business mailing address

125 S LAUREL RD
LONDON KY
40744-8300
US

V. Phone/Fax

Practice location:
  • Phone: 606-770-5086
  • Fax: 863-456-1301
Mailing address:
  • Phone: 606-770-5086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1158287
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4027957
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: