Provider Demographics
NPI:1669890927
Name:ELLSWORTH, KRISTEN WILSON (FNP)
Entity type:Individual
Prefix:MRS
First Name:KRISTEN
Middle Name:WILSON
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:A
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:151 ADAMS LN
Mailing Address - Street 2:SUITE 13
Mailing Address - City:MOUNT JULIET
Mailing Address - State:TN
Mailing Address - Zip Code:37122-3598
Mailing Address - Country:US
Mailing Address - Phone:615-288-4087
Mailing Address - Fax:
Practice Address - Street 1:151 ADAMS LN
Practice Address - Street 2:SUITE 13
Practice Address - City:MOUNT JULIET
Practice Address - State:TN
Practice Address - Zip Code:37122-3598
Practice Address - Country:US
Practice Address - Phone:615-288-4087
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-03
Last Update Date:2017-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN18503363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ011560Medicaid
TN1669890927Medicare NSC