Provider Demographics
NPI:1013542208
Name:ELLSWORTH, EMMA (LAC)
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 NW NORTH RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97229-2593
Mailing Address - Country:US
Mailing Address - Phone:804-878-9522
Mailing Address - Fax:
Practice Address - Street 1:12778 SE STARK ST # 125
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1539
Practice Address - Country:US
Practice Address - Phone:503-317-3113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-08
Last Update Date:2020-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC196567171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist