Provider Demographics
NPI:1851331508
Name:WATSON, ELLEN C (APRN)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:C
Last Name:WATSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 MALLETTS BAY AVE STE B
Mailing Address - Street 2:
Mailing Address - City:WINOOSKI
Mailing Address - State:VT
Mailing Address - Zip Code:05404-1960
Mailing Address - Country:US
Mailing Address - Phone:802-655-4422
Mailing Address - Fax:802-861-2678
Practice Address - Street 1:32 MALLETTS BAY AVE STE B
Practice Address - Street 2:
Practice Address - City:WINOOSKI
Practice Address - State:VT
Practice Address - Zip Code:05404-1960
Practice Address - Country:US
Practice Address - Phone:802-655-4422
Practice Address - Fax:802-861-2678
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2014-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT101023489363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT69295OtherVERMONT MANAGED CARE
VT69295OtherBLUE CROSS BLUE SHIELD
VT1012575Medicaid
VT0023489OtherFLETCHER ALLEN PREFERRED
VT389625OtherMVP
VT69295OtherBLUE CROSS BLUE SHIELD
VT1012575Medicaid