Provider Demographics
NPI:1174030068
Name:MCPHETRES, ELLEN DICKIE (REGISTERED NURSE)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:DICKIE
Last Name:MCPHETRES
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 HANOVER ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:NH
Mailing Address - Zip Code:03766-1312
Mailing Address - Country:US
Mailing Address - Phone:603-448-0126
Mailing Address - Fax:
Practice Address - Street 1:163 SUMMER ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:NH
Practice Address - Zip Code:03773-1208
Practice Address - Country:US
Practice Address - Phone:603-863-1785
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-02
Last Update Date:2024-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH037391-21163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3077550Medicaid