Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225400000X | Rehabilitation Practitioner |
NPI | 1003467622 |
---|---|
Provider Name | Bonnie Lewis |
First Address | Waterloo, IL 62298-1059 |
Second Address | Waterloo, IL 62298-1059 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/09/2019 |
Last Update Date | 25/09/2019 |