Provider Demographics
NPI:1053758441
Name:LEWIS, STEFANIE KRISTINE
Entity type:Individual
Prefix:
First Name:STEFANIE
Middle Name:KRISTINE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1045 CHANNINGWAY DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-9252
Mailing Address - Country:US
Mailing Address - Phone:937-878-8645
Mailing Address - Fax:937-878-8646
Practice Address - Street 1:1045 CHANNINGWAY DR
Practice Address - Street 2:
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-9252
Practice Address - Country:US
Practice Address - Phone:937-878-8645
Practice Address - Fax:937-878-8646
Is Sole Proprietor?:No
Enumeration Date:2013-05-27
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.129803207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0220395Medicaid