Provider Demographics
NPI:1902396286
Name:LEWELLYN, GENEVIEVE PATRICIA
Entity Type:Individual
Prefix:
First Name:GENEVIEVE
Middle Name:PATRICIA
Last Name:LEWELLYN
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 1:1184 UPTON RD
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36305-5134
Mailing Address - Country:US
Mailing Address - Phone:334-692-3517
Mailing Address - Fax:
Practice Address - Street 1:1184 UPTON RD
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-5134
Practice Address - Country:US
Practice Address - Phone:334-692-3517
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-13
Last Update Date:2018-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL2824622363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner