Provider Demographics
NPI:1770251860
Name:ELLAM, LAURIE A (APRN-PMHNP -BC)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:A
Last Name:ELLAM
Suffix:
Gender:F
Credentials:APRN-PMHNP -BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 749
Mailing Address - Street 2:
Mailing Address - City:MORRISVILLE
Mailing Address - State:VT
Mailing Address - Zip Code:05661-0749
Mailing Address - Country:US
Mailing Address - Phone:802-851-8704
Mailing Address - Fax:
Practice Address - Street 1:607 WASHINGTON HWY
Practice Address - Street 2:
Practice Address - City:MORRISVILLE
Practice Address - State:VT
Practice Address - Zip Code:05661-8652
Practice Address - Country:US
Practice Address - Phone:802-888-8320
Practice Address - Fax:802-888-8136
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-02
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101.0134947363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT6708137Medicaid