Healthcare Provider Details

I. General information

NPI: 1073454021
Provider Name (Legal Business Name): AQUARIA LEWIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2026
Last Update Date: 04/03/2026
Certification Date: 04/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 ELLA CIR
BOSSIER CITY LA
71112-3729
US

IV. Provider business mailing address

1215 ELLA CIR
BOSSIER CITY LA
71112-3729
US

V. Phone/Fax

Practice location:
  • Phone: 318-402-2168
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number010661151
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: