Provider Demographics
NPI:1508198235
Name:MCEWAN, CARLA RENELLE (LPN)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:RENELLE
Last Name:MCEWAN
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 W. BROADWAY
Mailing Address - Street 2:
Mailing Address - City:EL DORADO SPRINGS
Mailing Address - State:MO
Mailing Address - Zip Code:64744
Mailing Address - Country:US
Mailing Address - Phone:417-876-5314
Mailing Address - Fax:417-876-5328
Practice Address - Street 1:107 W BROADWAY ST
Practice Address - Street 2:
Practice Address - City:EL DORADO SPRINGS
Practice Address - State:MO
Practice Address - Zip Code:64744-1133
Practice Address - Country:US
Practice Address - Phone:417-876-5314
Practice Address - Fax:417-876-5328
Is Sole Proprietor?:No
Enumeration Date:2010-02-05
Last Update Date:2010-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO045102164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse