Healthcare Provider Details

I. General information

NPI: 1235651704
Provider Name (Legal Business Name): CHANTE M EWING
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2017
Last Update Date: 09/29/2026
Certification Date: 01/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3350 S STONEGATE CIR APT 102
NEW BERLIN WI
53151-4587
US

IV. Provider business mailing address

3350 S STONEGATE CIR APT 102
NEW BERLIN WI
53151-4587
US

V. Phone/Fax

Practice location:
  • Phone: 414-460-0618
  • Fax:
Mailing address:
  • Phone: 414-460-0618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number233443
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: