Provider Demographics
NPI:1578086740
Name:ELLSWORTH, PATRICIA (DNP)
Entity Type:Individual
Prefix:DR
First Name:PATRICIA
Middle Name:
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2344 N 840 W
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:UT
Mailing Address - Zip Code:84015-9726
Mailing Address - Country:US
Mailing Address - Phone:801-540-2698
Mailing Address - Fax:
Practice Address - Street 1:2132 N 1700 W
Practice Address - Street 2:STE 110
Practice Address - City:LAYTON
Practice Address - State:UT
Practice Address - Zip Code:84041-7059
Practice Address - Country:US
Practice Address - Phone:801-779-3500
Practice Address - Fax:801-779-3508
Is Sole Proprietor?:No
Enumeration Date:2017-07-19
Last Update Date:2022-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5232048-4405363LF0000X, 363L00000X
UT5232048163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1578086740Medicaid