Provider Demographics
NPI:1710130463
Name:RED OWL, EVELYN K (RN)
Entity Type:Individual
Prefix:
First Name:EVELYN
Middle Name:K
Last Name:RED OWL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:EAST HIGHWAY 18
Mailing Address - Street 2:
Mailing Address - City:PINE RIDGE
Mailing Address - State:SD
Mailing Address - Zip Code:57770
Mailing Address - Country:US
Mailing Address - Phone:605-867-5131
Mailing Address - Fax:
Practice Address - Street 1:E HWY 18
Practice Address - Street 2:E HWY 18
Practice Address - City:PINE RIDGE
Practice Address - State:SD
Practice Address - Zip Code:57770-1201
Practice Address - Country:US
Practice Address - Phone:605-867-5131
Practice Address - Fax:605-867-3097
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR45381163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse