Provider Demographics
NPI:1124186069
Name:ELLINGSWORTH, CHRISTINE A (LPN)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:A
Last Name:ELLINGSWORTH
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:219 SAINT MARY ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-2136
Mailing Address - Country:US
Mailing Address - Phone:315-785-9148
Mailing Address - Fax:
Practice Address - Street 1:81 CHURCH STREET
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:NY
Practice Address - Zip Code:13607
Practice Address - Country:US
Practice Address - Phone:315-482-9719
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY134871-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse