Provider Demographics
NPI:1699035287
Name:ELLENWOOD, BRIDGETTE (LPN)
Entity Type:Individual
Prefix:
First Name:BRIDGETTE
Middle Name:
Last Name:ELLENWOOD
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14619-2216
Mailing Address - Country:US
Mailing Address - Phone:585-235-3430
Mailing Address - Fax:
Practice Address - Street 1:22 FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14619-2216
Practice Address - Country:US
Practice Address - Phone:585-235-3430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-17
Last Update Date:2012-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY281266164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse