Healthcare Provider Details

I. General information

NPI: 1285698167
Provider Name (Legal Business Name): MARTHA LEWIS MAXWELL CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARTHA LEE LEWIS CRNA

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 12/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15790 PAUL VEGA MD DR
HAMMOND LA
70403-1434
US

IV. Provider business mailing address

PO BOX 2668
HAMMOND LA
70404-2668
US

V. Phone/Fax

Practice location:
  • Phone: 985-230-1682
  • Fax: 985-230-1617
Mailing address:
  • Phone: 985-230-2198
  • Fax: 985-230-2159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP01339
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: