Provider Demographics
NPI:1235651704
Name:EWING, CHANTE M
Entity Type:Individual
Prefix:
First Name:CHANTE
Middle Name:M
Last Name:EWING
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3350 S STONEGATE CIR APT 102
Mailing Address - Street 2:
Mailing Address - City:NEW BERLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53151-4587
Mailing Address - Country:US
Mailing Address - Phone:414-460-0618
Mailing Address - Fax:
Practice Address - Street 1:3350 S STONEGATE CIR APT 102
Practice Address - Street 2:
Practice Address - City:NEW BERLIN
Practice Address - State:WI
Practice Address - Zip Code:53151-4587
Practice Address - Country:US
Practice Address - Phone:414-460-0618
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI233443163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1235651704Medicaid