Healthcare Provider Details

I. General information

NPI: 1467535138
Provider Name (Legal Business Name): AMANDA G LEWIS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 01/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1055 N 300 W STE 401
PROVO UT
84604-3306
US

IV. Provider business mailing address

1055 N 300 W SUITE 401
PROVO UT
84604-3344
US

V. Phone/Fax

Practice location:
  • Phone: 801-357-7499
  • Fax: 801-373-5980
Mailing address:
  • Phone: 801-357-7499
  • Fax: 801-373-5980

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4980126-4405
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: