Healthcare Provider Details

I. General information

NPI: 1720997778
Provider Name (Legal Business Name): BONITA LEWIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2026
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15004 VERONICA AVE
EASTPOINTE MI
48021-2852
US

IV. Provider business mailing address

15004 VERONICA AVE
EASTPOINTE MI
48021-2852
US

V. Phone/Fax

Practice location:
  • Phone: 586-744-0747
  • Fax:
Mailing address:
  • Phone: 586-744-0747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: