Provider Demographics
NPI:1538500400
Name:DESIMONE, ELLEN NICOLE (ARNP)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:NICOLE
Last Name:DESIMONE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 BLACK OAK LN
Mailing Address - Street 2:
Mailing Address - City:ORMOND BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32174-4897
Mailing Address - Country:US
Mailing Address - Phone:386-295-2258
Mailing Address - Fax:
Practice Address - Street 1:200 BOOTH RD
Practice Address - Street 2:SUITE A
Practice Address - City:ORMOND BEACH
Practice Address - State:FL
Practice Address - Zip Code:32174-5715
Practice Address - Country:US
Practice Address - Phone:386-425-1212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-08
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9254081363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily