Provider Demographics
NPI:1861864381
Name:ELLSWORTH, MELANIE (ATC)
Entity Type:Individual
Prefix:
First Name:MELANIE
Middle Name:
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10533 GODDARD STREET
Mailing Address - Street 2:APT 331
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66214
Mailing Address - Country:US
Mailing Address - Phone:209-872-0711
Mailing Address - Fax:
Practice Address - Street 1:10533 GODDARD STREET
Practice Address - Street 2:APT 331
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66214
Practice Address - Country:US
Practice Address - Phone:209-872-0711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-23
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS24-009622255A2300X
MO20140249872255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer