Provider Demographics
NPI:1043781552
Name:ELY, KRISTEN KATHARINA (PA)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:KATHARINA
Last Name:ELY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:KATHARINA
Other - Last Name:GLICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:555 WASHINGTON HWY
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05661-8972
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:555 WASHINGTON HWY
Practice Address - Street 2:
Practice Address - City:MORRISVILLE
Practice Address - State:VT
Practice Address - Zip Code:05661
Practice Address - Country:US
Practice Address - Phone:802-760-6291
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-10
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT055.0031410363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant