Provider Demographics
NPI:1710798764
Name:LEWIS, TATYANAH
Entity type:Individual
Prefix:
First Name:TATYANAH
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 1:2321 GAGE AVE NE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44705-2123
Mailing Address - Country:US
Mailing Address - Phone:234-253-2949
Mailing Address - Fax:
Practice Address - Street 1:2321 GAGE AVE NE
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44705-2123
Practice Address - Country:US
Practice Address - Phone:234-253-2949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-17
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty