Provider Demographics
NPI:1033871397
Name:LEWIS, MICHELLE MINOUX
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:MINOUX
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 1:500 WESTCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HARRISON
Mailing Address - State:NY
Mailing Address - Zip Code:10604-3200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 WESTCHESTER AVE
Practice Address - Street 2:
Practice Address - City:WEST HARRISON
Practice Address - State:NY
Practice Address - Zip Code:10604-3200
Practice Address - Country:US
Practice Address - Phone:914-540-5593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-13
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY676156163W00000X
NYF30979301363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered Nurse