Provider Demographics
NPI:1952928756
Name:JEWETT, PELAGIE MCKENZIE (CNA)
Entity Type:Individual
Prefix:
First Name:PELAGIE
Middle Name:MCKENZIE
Last Name:JEWETT
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24276 166TH STREET AIRPORT ROAD
Mailing Address - Street 2:
Mailing Address - City:EAGLE BUTTE
Mailing Address - State:SD
Mailing Address - Zip Code:57625
Mailing Address - Country:US
Mailing Address - Phone:605-850-8813
Mailing Address - Fax:
Practice Address - Street 1:24276 166TH STREET AIRPORT ROAD
Practice Address - Street 2:
Practice Address - City:EAGLE BUTTE
Practice Address - State:SD
Practice Address - Zip Code:57625
Practice Address - Country:US
Practice Address - Phone:605-850-8813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-29
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDA049898376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
SDA049898OtherSD CERTIFIED NURSE AIDE