Provider Demographics
NPI:1386405942
Name:MCEWAN, KATELYN RAE (NP)
Entity type:Individual
Prefix:
First Name:KATELYN
Middle Name:RAE
Last Name:MCEWAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KATELYN
Other - Middle Name:
Other - Last Name:MACIEJEWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3245 HEALTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-1380
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:721 6TH AVE STE A
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093-8378
Practice Address - Country:US
Practice Address - Phone:269-273-9782
Practice Address - Fax:269-273-9711
Is Sole Proprietor?:No
Enumeration Date:2024-01-22
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704329768363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1386405942Medicaid