Provider Demographics
NPI:1720044621
Name:ELLWOOD, SUE A (CNP)
Entity Type:Individual
Prefix:
First Name:SUE
Middle Name:A
Last Name:ELLWOOD
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1740 CLEVELAND RD
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-2204
Mailing Address - Country:US
Mailing Address - Phone:330-287-4500
Mailing Address - Fax:
Practice Address - Street 1:1740 CLEVELAND RD
Practice Address - Street 2:
Practice Address - City:WOOSTER
Practice Address - State:OH
Practice Address - Zip Code:44691-2204
Practice Address - Country:US
Practice Address - Phone:330-287-4850
Practice Address - Fax:330-264-9804
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN168210363L00000X
OHNP05864363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2652713Medicaid
OHELNP07421Medicare PIN
P25809Medicare UPIN