Provider Demographics
NPI:1255680211
Name:ELLSWORTH, PAULA LOU (NP)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:LOU
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 E ELM ST
Mailing Address - Street 2:
Mailing Address - City:CARSON CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48811-9693
Mailing Address - Country:US
Mailing Address - Phone:989-584-3131
Mailing Address - Fax:989-584-6734
Practice Address - Street 1:114 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:MI
Practice Address - Zip Code:48847-1132
Practice Address - Country:US
Practice Address - Phone:989-875-4166
Practice Address - Fax:989-875-5168
Is Sole Proprietor?:No
Enumeration Date:2012-09-06
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704187187363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily