Provider Demographics
NPI:1447347620
Name:LEWIS, WYN (MA, MPH, CDE)
Entity type:Individual
Prefix:
First Name:WYN
Middle Name:
Last Name:LEWIS
Suffix:
Gender:F
Credentials:MA, MPH, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:214 SERENO DR
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501-1536
Mailing Address - Country:US
Mailing Address - Phone:505-983-3635
Mailing Address - Fax:505-983-2902
Practice Address - Street 1:214 SERENO DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87501-1536
Practice Address - Country:US
Practice Address - Phone:505-983-3635
Practice Address - Fax:505-983-2902
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM76121101YM0800X
NM093133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Not Answered133N00000XDietary & Nutritional Service ProvidersNutritionist