MEDICARE: KRISTIN LEWIS STORES ARNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LA2200X	Adult Health Nurse Practitioner	ARNP9246928	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	P01070656	OTHER	FL	RR MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083927073
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTIN LEWIS STORES ARNP

Provider Business Mailing Address
First Line	:	PO BOX 43667
Second Line	:	CREDENTIALING DEPARTMENT
City	:	JACKSONVILLE
State	:	FL
Zip	:	32203-3667
Country	:	US
Telephone Number	:	904-398-3760
Fax Number	:	904-338-0852

Provider Business Practice Location Address
First Line	:	14546 OLD SAINT AUGUSTINE RD STE 103
Second Line	:	CREDENTIALING DEPARTMENT
City	:	JACKSONVILLE
State	:	FL
Zip	:	32258-5469
Country	:	US
Telephone Number	:	904-338-0855
Fax Number	:	904-338-0852

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/19/2010
Last Update Date	:	11/18/2015

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