Provider Demographics
NPI:1255678652
Name:ELLENS, STEPHANIE MARCHETTA (PA)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:MARCHETTA
Last Name:ELLENS
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:21 COBB TER
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14620-3339
Mailing Address - Country:US
Mailing Address - Phone:810-429-0430
Mailing Address - Fax:585-276-1499
Practice Address - Street 1:2180 S CLINTON AVE OFC
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14618-2665
Practice Address - Country:US
Practice Address - Phone:852-255-7675
Practice Address - Fax:585-276-1499
Is Sole Proprietor?:No
Enumeration Date:2013-01-07
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5601006573363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant