Provider Demographics
NPI:1871865477
Name:ELLSWORTH-WOLK, JEAN MARIE (RN)
Entity Type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:MARIE
Last Name:ELLSWORTH-WOLK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5891 BRIARHILL DR
Mailing Address - Street 2:
Mailing Address - City:SOLON
Mailing Address - State:OH
Mailing Address - Zip Code:44139-2366
Mailing Address - Country:US
Mailing Address - Phone:440-349-0447
Mailing Address - Fax:
Practice Address - Street 1:18200 LORAIN AVE
Practice Address - Street 2:LOWER LEVEL
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44111-5605
Practice Address - Country:US
Practice Address - Phone:216-476-0683
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNS-01789364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist