Healthcare Provider Details

I. General information

NPI: 1285044552
Provider Name (Legal Business Name): EDNA MARIE LEWIS CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: EDNA MARIE TUCKER CNM

II. Dates (important events)

Enumeration Date: 05/07/2014
Last Update Date: 10/19/2022
Certification Date: 10/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

880 MADISON AVE
MEMPHIS TN
38103-3409
US

IV. Provider business mailing address

877 JEFFERSON AVE ATTN: PROVIDER ENROLLMENT
MEMPHIS TN
38103-2807
US

V. Phone/Fax

Practice location:
  • Phone: 901-515-3800
  • Fax: 901-302-2491
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberAP5499
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number22028
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: