Healthcare Provider Details

I. General information

NPI: 1740109933
Provider Name (Legal Business Name): KIMBERLY EWEN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

118 W DREXEL PKWY
RENSSELAER IN
47978-7344
US

IV. Provider business mailing address

PO BOX 781076
DETROIT MI
48278-1076
US

V. Phone/Fax

Practice location:
  • Phone: 219-866-4300
  • Fax: 219-866-7591
Mailing address:
  • Phone: 317-528-4800
  • Fax: 317-865-1479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28271510A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: