Provider Demographics
NPI:1972767135
Name:O'ROURKE, ELLEN S (LIC AC)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:S
Last Name:O'ROURKE
Suffix:
Gender:F
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 MAIN ST STE 926
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01608-2503
Mailing Address - Country:US
Mailing Address - Phone:508-754-9287
Mailing Address - Fax:
Practice Address - Street 1:390 MAIN ST
Practice Address - Street 2:SUITE 926
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-2583
Practice Address - Country:US
Practice Address - Phone:508-754-9287
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA213171100000X
MARN237734363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No171100000XOther Service ProvidersAcupuncturist