Provider Demographics
NPI:1861651275
Name:ELLSWORTH, MELINDA
Entity Type:Individual
Prefix:
First Name:MELINDA
Middle Name:
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:PO BOX 1894
Mailing Address - Street 2:
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50402-1894
Mailing Address - Country:US
Mailing Address - Phone:641-494-3041
Mailing Address - Fax:641-494-3059
Practice Address - Street 1:308 N MAPLE AVE
Practice Address - Street 2:
Practice Address - City:NEW HAMPTON
Practice Address - State:IA
Practice Address - Zip Code:50659-1142
Practice Address - Country:US
Practice Address - Phone:641-394-4121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-02
Last Update Date:2008-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA709845133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered