Provider Demographics
NPI:1356037907
Name:BRADDOCK, ELLEN MAREN (RN)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:MAREN
Last Name:BRADDOCK
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:PO BOX 92
Mailing Address - Street 2:
Mailing Address - City:WASHBURN
Mailing Address - State:WI
Mailing Address - Zip Code:54891-0092
Mailing Address - Country:US
Mailing Address - Phone:715-220-2630
Mailing Address - Fax:
Practice Address - Street 1:126 W BAYFIELD ST STE 2
Practice Address - Street 2:
Practice Address - City:WASHBURN
Practice Address - State:WI
Practice Address - Zip Code:54891-1182
Practice Address - Country:US
Practice Address - Phone:715-220-2630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-17
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIDKX-2P4163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health