Provider Demographics
NPI:1164454328
Name:LEWIS, WENDY ELIZABETH (NP)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:ELIZABETH
Last Name:LEWIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:106 HILLSIDE DR
Mailing Address - Street 2:
Mailing Address - City:RINCON
Mailing Address - State:GA
Mailing Address - Zip Code:31326-4852
Mailing Address - Country:US
Mailing Address - Phone:912-667-8455
Mailing Address - Fax:
Practice Address - Street 1:455 S MAIN ST STE 105
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-4354
Practice Address - Country:US
Practice Address - Phone:912-876-5505
Practice Address - Fax:912-876-5508
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN098343363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA50BBKLLOtherTERM'D MEDICARE PTAN
GA403969OtherWELLCARE
GA01067628OtherAMERIGROUP
GAP00456205OtherRR MEDICARE
GA305396678AMedicaid
SCNP2499Medicaid
GAP00456205OtherRR MEDICARE
GA50BBKLLOtherTERM'D MEDICARE PTAN