Healthcare Provider Details

I. General information

NPI: 1235627142
Provider Name (Legal Business Name): MIJANOU D MARRETTA-LEWIS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2018
Last Update Date: 07/17/2025
Certification Date: 07/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1989 MIAMISBURG CENTERVILLE RD STE 301
CENTERVILLE OH
45459-3858
US

IV. Provider business mailing address

1989 MIAMISBURG CENTERVILLE RD STE 301
CENTERVILLE OH
45459-3858
US

V. Phone/Fax

Practice location:
  • Phone: 937-434-7353
  • Fax: 937-438-6569
Mailing address:
  • Phone: 937-434-7353
  • Fax: 937-438-6569

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN.CNP.022588
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: