=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700886611
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHELE THERESE LEWIS CRNA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2005
-----------------------------------------------------
Last Update Date | 05/22/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 607 BEAMAN ST ANESTHESIA DEPARTMENT
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28328-2603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-592-8511
-----------------------------------------------------
Fax | 910-592-8511
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 890235
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28289-0235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-919-1190
-----------------------------------------------------
Fax | 800-919-1190
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 367500000X
-----------------------------------------------------
Taxonomy Name | Certified Registered Nurse Anesthetist
-----------------------------------------------------
License Number | 121721
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------