Provider Demographics
NPI:1710541487
Name:ELLSWORTH, KELLEY ANNE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:KELLEY
Middle Name:ANNE
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3135 38TH ST NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20016-3726
Mailing Address - Country:US
Mailing Address - Phone:202-744-4983
Mailing Address - Fax:
Practice Address - Street 1:3301 NEW MEXICO AVE NW STE 205
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20016-3627
Practice Address - Country:US
Practice Address - Phone:202-243-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-27
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCPA031761363A00000X
MAPA7445363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant