Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QS0010X | Family Doctor - Sports Medicine | DO2912 | ME |
NPI | 1104289990 |
---|---|
Provider Name | Stefanie Lauren Lewis |
First Address | Springfield, MA 01199-1001 |
Second Address | Augusta, ME 04330-5758 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/03/2016 |
Last Update Date | 13/06/2019 |