MEDICARE: NICOLE LEWIS LMP, LMT, MMP

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	225700000X	Massage Therapist	MA24601	WA
2	225700000X	Massage Therapist	15323	OR

General Provider Information

NPI Number	:	1891969788
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE LEWIS LMP, LMT, MMP

Provider Business Mailing Address
First Line	:	7408 NE 87TH CIR
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98662-2827
Country	:	US
Telephone Number	:	360-989-0312
Fax Number	:	360-567-0620

Provider Business Practice Location Address
First Line	:	2402 BROADWAY ST
Second Line	:
City	:	VANCOUVER
State	:	WA
Zip	:	98663-3229
Country	:	US
Telephone Number	:	360-989-0312
Fax Number	:	360-567-0620

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

Provider Enumeration Date	:	04/22/2008
Last Update Date	:	06/02/2013

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