Basic Information
| Provider Information | |||||||||
| NPI: | 1871926808 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EWING | ||||||||
| FirstName: | MOLLIE | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MISTER | ||||||||
| OtherFirstName: | MOLLIE | ||||||||
| OtherMiddleName: | K | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 301 RANDOLPH ST | ||||||||
| Address2: | PO BOX 660 | ||||||||
| City: | DENTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216290660 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104794306 | ||||||||
| FaxNumber: | 4104791714 | ||||||||
| Practice Location | |||||||||
| Address1: | 609 DAFFIN LANE | ||||||||
| Address2: | |||||||||
| City: | DENTON | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216291392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104792650 | ||||||||
| FaxNumber: | 4104791626 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2013 | ||||||||
| LastUpdateDate: | 08/13/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WD0400X | R182077 | MD | Y | Nursing Service Providers | Registered Nurse | Diabetes Educator |
No ID Information.