Provider Demographics
NPI:1114036803
Name:O'NEILL, ELLEN ANN (CNM)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:ANN
Last Name:O'NEILL
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 BENNETT AVE
Mailing Address - Street 2:
Mailing Address - City:KEARNY
Mailing Address - State:NJ
Mailing Address - Zip Code:07032-3113
Mailing Address - Country:US
Mailing Address - Phone:201-997-3535
Mailing Address - Fax:
Practice Address - Street 1:714 BERGEN AVE
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07306-4802
Practice Address - Country:US
Practice Address - Phone:201-434-7906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25ME00012001176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1479601Medicaid