Provider Demographics
NPI:1538446307
Name:EWING, NICOLE DENISE (MHPP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:DENISE
Last Name:EWING
Suffix:
Gender:F
Credentials:MHPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5412 SOUTHBORO DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72209-7870
Mailing Address - Country:US
Mailing Address - Phone:901-502-9595
Mailing Address - Fax:
Practice Address - Street 1:5412 SOUTHBORO DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72209-7870
Practice Address - Country:US
Practice Address - Phone:901-502-9595
Practice Address - Fax:501-955-7612
Is Sole Proprietor?:No
Enumeration Date:2011-11-08
Last Update Date:2012-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator