Healthcare Provider Details

I. General information

NPI: 1376709311
Provider Name (Legal Business Name): KOURTNEY L LEWIS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2008
Last Update Date: 05/25/2023
Certification Date: 05/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 JACKSON ST
MONROE LA
71201
US

IV. Provider business mailing address

211 LEWIS LN
WEST MONROE LA
71291-8771
US

V. Phone/Fax

Practice location:
  • Phone: 318-966-4190
  • Fax:
Mailing address:
  • Phone: 318-355-3396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP05530
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: