Provider Demographics
NPI:1093429243
Name:ELLSWORTH, JANNA
Entity Type:Individual
Prefix:
First Name:JANNA
Middle Name:
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18643 E ORIOLE WAY
Mailing Address - Street 2:
Mailing Address - City:QUEEN CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85142-5540
Mailing Address - Country:US
Mailing Address - Phone:928-242-4696
Mailing Address - Fax:
Practice Address - Street 1:18643 E ORIOLE WAY
Practice Address - Street 2:
Practice Address - City:QUEEN CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85142-5540
Practice Address - Country:US
Practice Address - Phone:928-242-4696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-12
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZF12220690363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily