Healthcare Provider Details

I. General information

NPI: 1700885274
Provider Name (Legal Business Name): ROSE M EWING FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2005
Last Update Date: 11/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 MICHIGAN AVE
LOGANSPORT IN
46947-1528
US

IV. Provider business mailing address

1101 MICHIGAN AVE
LOGANSPORT IN
46947-1528
US

V. Phone/Fax

Practice location:
  • Phone: 574-753-7541
  • Fax:
Mailing address:
  • Phone: 574-753-7541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71000503A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: