Provider Demographics
NPI:1255006797
Name:WILSON, ELLEN LOUISE (RN, CCM)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:LOUISE
Last Name:WILSON
Suffix:
Gender:F
Credentials:RN, CCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 792
Mailing Address - Street 2:620 CHESTNUT HILL RD
Mailing Address - City:DAYVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06241
Mailing Address - Country:US
Mailing Address - Phone:860-234-1310
Mailing Address - Fax:
Practice Address - Street 1:620 CHESTNUT HILL RD
Practice Address - Street 2:
Practice Address - City:DAYVILLE
Practice Address - State:CT
Practice Address - Zip Code:06241
Practice Address - Country:US
Practice Address - Phone:860-234-1310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-16
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT081384163W00000X, 163WH0200X, 163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163W00000XNursing Service ProvidersRegistered Nurse
No163WH0200XNursing Service ProvidersRegistered NurseHome Health