Provider Demographics
NPI:1124218466
Name:LEWIS, DORESEA L (APRN,BC)
Entity type:Individual
Prefix:MRS
First Name:DORESEA
Middle Name:L
Last Name:LEWIS
Suffix:
Gender:F
Credentials:APRN,BC
Other - Prefix:
Other - First Name:DORESEA
Other - Middle Name:L
Other - Last Name:LEWIS-BOGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:400 MACK AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2136
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3901 CHRYSLER DR STE 3B
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2167
Practice Address - Country:US
Practice Address - Phone:313-577-1396
Practice Address - Fax:313-577-1419
Is Sole Proprietor?:No
Enumeration Date:2007-08-01
Last Update Date:2025-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704241492363LP0808X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1124218466Medicaid