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General NPI Number Information
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NPI Number | 1093167074
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Entity Type | Individual
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Provider Name | BRYCE ALEXANDRA LEWELLEN O.D.
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Gender | Female
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Dates
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Enumeration Date | 07/01/2016
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Last Update Date | 10/02/2023
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Provider Practice Location Address
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Address Line | 5300 MEMORIAL DR
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City | TWO RIVERS
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State | WI
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Zip | 54241-3923
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Country | US
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Telephone | 920-793-7515
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Fax | 920-793-7516
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Provider Business Mailing Address
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Address Line | PO BOX 735044
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City | CHICAGO
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State | IL
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Zip | 60673-5044
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 3647
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License Number State | WI
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