Provider Demographics
NPI:1508364712
Name:MAXFIELD, ELLEN M (MS, CHES)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:M
Last Name:MAXFIELD
Suffix:
Gender:F
Credentials:MS, CHES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 S WAKARA WAY RM B140
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1213
Mailing Address - Country:US
Mailing Address - Phone:801-213-3468
Mailing Address - Fax:
Practice Address - Street 1:520 S WAKARA WAY
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1213
Practice Address - Country:US
Practice Address - Phone:801-213-8720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2018-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator