Provider Demographics
NPI:1720352529
Name:ELLSWORTH, CAROL MARIE (NP-C)
Entity Type:Individual
Prefix:MS
First Name:CAROL
Middle Name:MARIE
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 476 BOX 25
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96322-0001
Mailing Address - Country:US
Mailing Address - Phone:315-252-2589
Mailing Address - Fax:
Practice Address - Street 1:PSC 476 BOX 25
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96322-0001
Practice Address - Country:US
Practice Address - Phone:315-252-2589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-27
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC187197363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily