Provider Demographics
NPI:1134107204
Name:IACOVONE, ELLEN M (CNP)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:M
Last Name:IACOVONE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:M
Other - Last Name:BOWENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 73327N
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-1094
Mailing Address - Country:US
Mailing Address - Phone:440-879-0081
Mailing Address - Fax:440-879-0084
Practice Address - Street 1:12300 MCCRACKEN RD
Practice Address - Street 2:
Practice Address - City:GARFIELD HTS
Practice Address - State:OH
Practice Address - Zip Code:44125-2914
Practice Address - Country:US
Practice Address - Phone:216-581-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2007-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP-03023363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000324165OtherANTHEM
OH2185862Medicaid
OH000000324165OtherANTHEM
OH2185862Medicaid