Provider Demographics
NPI:1952302267
Name:KAWADLER, ELLEN DIANNE (APRN, BC, FNP)
Entity Type:Individual
Prefix:MRS
First Name:ELLEN
Middle Name:DIANNE
Last Name:KAWADLER
Suffix:
Gender:F
Credentials:APRN, BC, FNP
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:DIANNE
Other - Last Name:KNOFF
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:64 FURNACE ST
Mailing Address - Street 2:
Mailing Address - City:SHARON
Mailing Address - State:MA
Mailing Address - Zip Code:02067-2808
Mailing Address - Country:US
Mailing Address - Phone:781-784-7807
Mailing Address - Fax:
Practice Address - Street 1:1071 BLUE HILL AVE
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:MA
Practice Address - Zip Code:02186-2302
Practice Address - Country:US
Practice Address - Phone:617-333-2394
Practice Address - Fax:617-333-2029
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA137476363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP2257Medicare UPIN