Provider Demographics
NPI:1497306336
Name:SUPERDOCK, ELLEN R (CRNP)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:R
Last Name:SUPERDOCK
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 N WATER ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:PA
Mailing Address - Zip Code:17603-3374
Mailing Address - Country:US
Mailing Address - Phone:717-735-6808
Mailing Address - Fax:717-325-8057
Practice Address - Street 1:920 CHURCH ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:PA
Practice Address - Zip Code:17046-4656
Practice Address - Country:US
Practice Address - Phone:717-272-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-23
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP020508363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily