Provider Demographics
NPI:1851717193
Name:FORD, ELLESE MARIE
Entity Type:Individual
Prefix:
First Name:ELLESE
Middle Name:MARIE
Last Name:FORD
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 1:6000 BASS LAKE RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:CRYSTAL
Mailing Address - State:MN
Mailing Address - Zip Code:55429-2700
Mailing Address - Country:US
Mailing Address - Phone:612-998-9838
Mailing Address - Fax:763-432-3919
Practice Address - Street 1:6000 BASS LAKE RD
Practice Address - Street 2:SUITE 105
Practice Address - City:CRYSTAL
Practice Address - State:MN
Practice Address - Zip Code:55429-2700
Practice Address - Country:US
Practice Address - Phone:612-998-9838
Practice Address - Fax:763-432-3919
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-11
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant