Healthcare Provider Details

I. General information

NPI: 1144669144
Provider Name (Legal Business Name): JILLIAN SUE LEWIS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2013
Last Update Date: 10/23/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1740 CLEVELAND RD
WOOSTER OH
44691-2204
US

IV. Provider business mailing address

PO BOX 1239
TROY MI
48099-1239
US

V. Phone/Fax

Practice location:
  • Phone: 330-287-4500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCOA. 14653-NP
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: