Provider Demographics
NPI:1629512298
Name:WALSH, ELLEN THERESA (CNP)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:THERESA
Last Name:WALSH
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:489 BERNARDSTON RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:GREENFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01301-1238
Mailing Address - Country:US
Mailing Address - Phone:570-575-0172
Mailing Address - Fax:
Practice Address - Street 1:489 BERNARDSTON RD
Practice Address - Street 2:SUITE 108
Practice Address - City:GREENFIELD
Practice Address - State:MA
Practice Address - Zip Code:01301-1238
Practice Address - Country:US
Practice Address - Phone:413-325-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-15
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2302937363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics