Provider Demographics
NPI:1174976773
Name:LEWIS, TERRY HUBERT (NP-C)
Entity type:Individual
Prefix:
First Name:TERRY
Middle Name:HUBERT
Last Name:LEWIS
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8137 E CREE LAKE DR S
Mailing Address - Street 2:
Mailing Address - City:KENDALLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46755-9721
Mailing Address - Country:US
Mailing Address - Phone:269-349-8386
Mailing Address - Fax:
Practice Address - Street 1:2725 AIRVIEW BLVD
Practice Address - Street 2:
Practice Address - City:PORTAGE
Practice Address - State:MI
Practice Address - Zip Code:49002-1803
Practice Address - Country:US
Practice Address - Phone:269-349-8386
Practice Address - Fax:269-349-8397
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-19
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704238831363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily