Healthcare Provider Details

I. General information

NPI: 1053058156
Provider Name (Legal Business Name): JENNIFER LYNN EWING RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2022
Last Update Date: 05/19/2022
Certification Date: 05/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1701 HAMILTON ST
DOUGLAS WY
82633-2781
US

IV. Provider business mailing address

1701 HAMILTON ST
DOUGLAS WY
82633-2781
US

V. Phone/Fax

Practice location:
  • Phone: 307-358-2940
  • Fax:
Mailing address:
  • Phone: 307-358-2940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number19023
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: