Provider Demographics
NPI:1083070593
Name:STEWART, CAROL LEE (FNP)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:LEE
Last Name:STEWART
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 280
Mailing Address - Street 2:
Mailing Address - City:WAGNER
Mailing Address - State:SD
Mailing Address - Zip Code:57380-0280
Mailing Address - Country:US
Mailing Address - Phone:605-384-3611
Mailing Address - Fax:
Practice Address - Street 1:513 3RD STREET SW
Practice Address - Street 2:
Practice Address - City:WAGNER
Practice Address - State:SD
Practice Address - Zip Code:57380
Practice Address - Country:US
Practice Address - Phone:605-384-3611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-13
Last Update Date:2016-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDCP001024363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily