MEDICARE: MARISSA LYNN LEWIS

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	390200000X	Student in an Organized Health Care Education/Training Program		OH

Other Identifiers

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

General Provider Information

NPI Number	:	1609321264
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARISSA LYNN LEWIS

Provider Business Mailing Address
First Line	:	1482 SPRING GARDEN AVE
Second Line	:
City	:	LAKEWOOD
State	:	OH
Zip	:	44107-3410
Country	:	US
Telephone Number	:	216-527-5016
Fax Number	:

Provider Business Practice Location Address
First Line	:	1482 SPRING GARDEN AVE
Second Line	:
City	:	LAKEWOOD
State	:	OH
Zip	:	44107-3410
Country	:	US
Telephone Number	:	216-527-5016
Fax Number	:

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

Provider Enumeration Date	:	08/23/2016
Last Update Date	:	08/23/2016

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Directions to “ MARISSA LYNN LEWIS ” Practice Location

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