Healthcare Provider Details

I. General information

NPI: 1093087249
Provider Name (Legal Business Name): LISA M EWAN APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2012
Last Update Date: 08/11/2023
Certification Date: 08/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 KINGS HWY STE 100
WEST DEPTFORD NJ
08096-3165
US

IV. Provider business mailing address

6 N BROAD ST SUITE 301
WOODBURY NJ
08096-4635
US

V. Phone/Fax

Practice location:
  • Phone: 856-251-0500
  • Fax:
Mailing address:
  • Phone: 856-251-0500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number26NJ00365500
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number26NJ00365500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: