Provider Demographics
NPI:1861156523
Name:LEWIS, BRANDY (LVN, DSD)
Entity type:Individual
Prefix:
First Name:BRANDY
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:LVN, DSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24055 CLINTON KEITH RD APT 315
Mailing Address - Street 2:
Mailing Address - City:WILDOMAR
Mailing Address - State:CA
Mailing Address - Zip Code:92595-8530
Mailing Address - Country:US
Mailing Address - Phone:760-497-5485
Mailing Address - Fax:
Practice Address - Street 1:624 E ELDER ST
Practice Address - Street 2:
Practice Address - City:FALLBROOK
Practice Address - State:CA
Practice Address - Zip Code:92028-3004
Practice Address - Country:US
Practice Address - Phone:760-451-4165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-28
Last Update Date:2021-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA200727164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse