Healthcare Provider Details

I. General information

NPI: 1144224114
Provider Name (Legal Business Name): MARY JANE LEWIS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2005
Last Update Date: 08/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1370 W D ST
N WILKESBORO NC
28659-3506
US

IV. Provider business mailing address

126 JOE OWENS RD
FLEETWOOD NC
28626-9663
US

V. Phone/Fax

Practice location:
  • Phone: 336-651-8100
  • Fax:
Mailing address:
  • Phone: 336-877-5799
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number172991
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: