Provider Demographics
NPI:1235486499
Name:ELLINGWOOD, AMY JENE (ANP)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:JENE
Last Name:ELLINGWOOD
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1040 SIERRA DR STE 400
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-7241
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:1630 LAFAYETTE RD STE 200
Practice Address - Street 2:
Practice Address - City:CRAWFORDSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47933-1092
Practice Address - Country:US
Practice Address - Phone:765-359-2230
Practice Address - Fax:765-359-2236
Is Sole Proprietor?:No
Enumeration Date:2012-08-07
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN2012011503363LA2200X
IN71004165A363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201115580Medicaid