Healthcare Provider Details

I. General information

NPI: 1043201056
Provider Name (Legal Business Name): DIANA LOUISE LEWIS N.P.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: DIANA LOUISE LEWIS N.P.

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 06/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NM STATE HIGHWAY 120, MILE MARKER 12.5
OCATE NM
87734
US

IV. Provider business mailing address

NM HIGHWAY 120 @MILE MARKER 12.5, SOUTH SIDE OF HIGHWAY P.O. BOX 203
OCATE NM
87734
US

V. Phone/Fax

Practice location:
  • Phone: 505-666-2475
  • Fax:
Mailing address:
  • Phone: 505-666-2475
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR24775
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: