Provider Demographics
NPI:1174990535
Name:MILES-LEWIS, ANGENIQUE
Entity type:Individual
Prefix:
First Name:ANGENIQUE
Middle Name:
Last Name:MILES-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 1:3901 W ARKANSAS LN STE 116
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76016-1400
Mailing Address - Country:US
Mailing Address - Phone:817-899-2224
Mailing Address - Fax:
Practice Address - Street 1:3901 W ARKANSAS LN STE 116
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76016-1400
Practice Address - Country:US
Practice Address - Phone:817-899-2224
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-01
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1047278174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX$$$$$$$$$Medicaid