Provider Demographics
NPI:1386231223
Name:TALBOTT, ELLEN (FNP)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:TALBOTT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4020 COPPER VW STE 104
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-7041
Mailing Address - Country:US
Mailing Address - Phone:231-421-6921
Mailing Address - Fax:
Practice Address - Street 1:815 BUSINESS PARK DR STE A
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-8683
Practice Address - Country:US
Practice Address - Phone:231-421-6921
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-27
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704282876363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner