=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568896454
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KIMBERLY NICOLE LEWIS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/27/2013
-----------------------------------------------------
Last Update Date | 02/13/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 717 K ST STE 425
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95814-3477
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-793-9823
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9671 IRIS MEADOW WAY
-----------------------------------------------------
City | ELK GROVE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95757-3227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-759-9628
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 95033804
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------