Provider Demographics
NPI:1730636879
Name:OBITZ-BOSSART, ELLEN LUISE (RN)
Entity Type:Individual
Prefix:MISS
First Name:ELLEN
Middle Name:LUISE
Last Name:OBITZ-BOSSART
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1620 21ST ST NW
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44709
Mailing Address - Country:US
Mailing Address - Phone:330-904-8415
Mailing Address - Fax:
Practice Address - Street 1:2950 WHIPPLE AVE NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-1534
Practice Address - Country:US
Practice Address - Phone:330-477-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN229930163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse