Provider Demographics
NPI:1841761582
Name:CHANG, ELLEN
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:CHANG
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:ELLEN
Other - Middle Name:
Other - Last Name:CHANG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MIRIAM ELLEN
Mailing Address - Street 1:1601 3RD AVE APT 20B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10128-3456
Mailing Address - Country:US
Mailing Address - Phone:917-747-0011
Mailing Address - Fax:
Practice Address - Street 1:1601 3RD AVE APT 20B
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10128-3456
Practice Address - Country:US
Practice Address - Phone:917-747-0011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-06
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374K00000XNursing Service Related ProvidersReligious Nonmedical PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NONEOtherNONE