Provider Demographics
NPI:1093788317
Name:EVANS, ELLEN GLORIA
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:GLORIA
Last Name:EVANS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:GLORIA
Other - Last Name:DE FILIPPIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1063
Mailing Address - Street 2:FAHC
Mailing Address - City:BURLINGTON
Mailing Address - State:VT
Mailing Address - Zip Code:05402-1063
Mailing Address - Country:US
Mailing Address - Phone:802-847-1400
Mailing Address - Fax:
Practice Address - Street 1:111 COLCHESTER AVE
Practice Address - Street 2:FLETCHER ALLEN HEALTH CARE
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401
Practice Address - Country:US
Practice Address - Phone:802-847-1400
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0740000195133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0802Medicare ID - Type Unspecified