Provider Demographics
NPI:1114591815
Name:ROSEEN, ELLEN A (LO)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:A
Last Name:ROSEEN
Suffix:
Gender:F
Credentials:LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:236 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-2004
Mailing Address - Country:US
Mailing Address - Phone:860-646-3577
Mailing Address - Fax:860-643-9733
Practice Address - Street 1:236 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042-2004
Practice Address - Country:US
Practice Address - Phone:860-646-3577
Practice Address - Fax:860-643-9733
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-17
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001298156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician