Provider Demographics
NPI:1811417272
Name:ELLSWORTH, LAUREN ELIZABETH
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:ELIZABETH
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:444 HOSPITAL WAY STE 477
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-2744
Mailing Address - Country:US
Mailing Address - Phone:208-233-7832
Mailing Address - Fax:
Practice Address - Street 1:444 HOSPITAL WAY STE 477
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-2744
Practice Address - Country:US
Practice Address - Phone:208-233-7832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCPSS415175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist