Provider Demographics
NPI:1144194952
Name:LEWIS, DERRIS LEQUISE
Entity type:Individual
Prefix:
First Name:DERRIS
Middle Name:LEQUISE
Last Name:LEWIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2007 DANA LN LOT 3
Mailing Address - Street 2:
Mailing Address - City:CONOVER
Mailing Address - State:NC
Mailing Address - Zip Code:28613-8176
Mailing Address - Country:US
Mailing Address - Phone:614-517-0268
Mailing Address - Fax:
Practice Address - Street 1:2007 DANA LN LOT 3
Practice Address - Street 2:
Practice Address - City:CONOVER
Practice Address - State:NC
Practice Address - Zip Code:28613-8176
Practice Address - Country:US
Practice Address - Phone:614-517-0268
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-03
Last Update Date:2025-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker