Provider Demographics
NPI:1770655995
Name:ELLINGSWORTH, CHRISTA LYNNE (NP)
Entity Type:Individual
Prefix:MR
First Name:CHRISTA
Middle Name:LYNNE
Last Name:ELLINGSWORTH
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 1:5724 SHANNON LN
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:MI
Mailing Address - Zip Code:48348-5165
Mailing Address - Country:US
Mailing Address - Phone:248-393-0043
Mailing Address - Fax:
Practice Address - Street 1:5724 SHANNON LN
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:MI
Practice Address - Zip Code:48348-5165
Practice Address - Country:US
Practice Address - Phone:248-393-0043
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704195469363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily