Provider Demographics
NPI:1790062768
Name:GINGERELLA, ELLEN (PA-C)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:GINGERELLA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:
Other - Last Name:FAULISE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:194 HOWARD ST
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-5544
Mailing Address - Country:US
Mailing Address - Phone:860-442-0564
Mailing Address - Fax:
Practice Address - Street 1:194 HOWARD ST
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-5544
Practice Address - Country:US
Practice Address - Phone:860-442-0564
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-04
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3249363A00000X
MAPA4239363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical