Provider Demographics
NPI:1679314066
Name:LEWIS, LATASHA
Entity type:Individual
Prefix:
First Name:LATASHA
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 1:2946 STRAUSS LN
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46239-1783
Mailing Address - Country:US
Mailing Address - Phone:317-628-3268
Mailing Address - Fax:
Practice Address - Street 1:2946 STRAUSS LN
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46239-1783
Practice Address - Country:US
Practice Address - Phone:317-628-3268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-01
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
343900000X
IN2310859705172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)