Provider Demographics
NPI:1053773994
Name:LEWIS, DONNA
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:
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 1:4 YANKEE PL
Mailing Address - Street 2:
Mailing Address - City:ELLENVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12428-1510
Mailing Address - Country:US
Mailing Address - Phone:845-647-6464
Mailing Address - Fax:
Practice Address - Street 1:4 YANKEE PL
Practice Address - Street 2:
Practice Address - City:ELLENVILLE
Practice Address - State:NY
Practice Address - Zip Code:12428-1510
Practice Address - Country:US
Practice Address - Phone:845-647-6464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-21
Last Update Date:2016-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY553582941174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist