Provider Demographics
NPI:1316566037
Name:ELLSWORTH, MICHELE LEE
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:LEE
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4542 E OLIVE AVE
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85234-7606
Mailing Address - Country:US
Mailing Address - Phone:480-776-9404
Mailing Address - Fax:
Practice Address - Street 1:4542 E OLIVE AVE
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85234-7606
Practice Address - Country:US
Practice Address - Phone:480-776-9404
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-13
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies