Provider Demographics
NPI:1134579972
Name:DAVIES, ELLEN CLARK (NP)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:CLARK
Last Name:DAVIES
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 E 102ND ST FL 3
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-5204
Mailing Address - Country:US
Mailing Address - Phone:212-241-7968
Mailing Address - Fax:212-824-2312
Practice Address - Street 1:17 E 102ND ST FL 3
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029
Practice Address - Country:US
Practice Address - Phone:212-241-7968
Practice Address - Fax:212-824-2312
Is Sole Proprietor?:No
Enumeration Date:2016-06-13
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY341606363LF0000X
NY623297163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05691387Medicaid