Provider Demographics
NPI:1720044035
Name:ELLINGTON, JUDITH M (NP)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:M
Last Name:ELLINGTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 WI DELLS PARKWAY SOUTH
Mailing Address - Street 2:
Mailing Address - City:LAKE DELTON
Mailing Address - State:WI
Mailing Address - Zip Code:53940-0390
Mailing Address - Country:US
Mailing Address - Phone:608-254-5400
Mailing Address - Fax:608-253-8585
Practice Address - Street 1:530 WI DELLS PKWY S
Practice Address - Street 2:
Practice Address - City:LAKE DELTON
Practice Address - State:WI
Practice Address - Zip Code:53940-0390
Practice Address - Country:US
Practice Address - Phone:608-254-5400
Practice Address - Fax:608-253-8585
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49722-030163W00000X
WI49722363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1720044035Medicaid
WIK400176326Medicare PIN
WI080179056Medicare PIN
WI003557155Medicare PIN
WI080179050Medicare PIN
WI1027535OtherPHYSICIANS PLUS
WIK400134791Medicare PIN