Provider Demographics
NPI:1568016244
Name:DILLARD, ELLEN WONG (NP-C)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:WONG
Last Name:DILLARD
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 JOHN R ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2013
Mailing Address - Country:US
Mailing Address - Phone:313-576-9096
Mailing Address - Fax:313-576-8422
Practice Address - Street 1:4100 JOHN R ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2013
Practice Address - Country:US
Practice Address - Phone:313-576-9096
Practice Address - Fax:313-576-8422
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-30
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704288766363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner