Healthcare Provider Details

I. General information

NPI: 1164409751
Provider Name (Legal Business Name): NELLIE BRUNO LEWIS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/27/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21230 DEQUINDRE RD
WARREN MI
48091-2279
US

IV. Provider business mailing address

3717 WALNUT BROOK DR
ROCHESTER HILLS MI
48309-4069
US

V. Phone/Fax

Practice location:
  • Phone: 586-880-2485
  • Fax: 586-759-0237
Mailing address:
  • Phone: 248-852-7902
  • Fax: 248-853-0671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4704097163
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: