Provider Demographics
NPI:1770525511
Name:ELLSWORTH, NORINE II
Entity type:Individual
Prefix:
First Name:NORINE
Middle Name:
Last Name:ELLSWORTH
Suffix:II
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 KINKAID DR
Mailing Address - Street 2:
Mailing Address - City:COUPEVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98239-9725
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:58 KINKAID DR
Practice Address - Street 2:
Practice Address - City:COUPEVILLE
Practice Address - State:WA
Practice Address - Zip Code:98239-9725
Practice Address - Country:US
Practice Address - Phone:360-678-5251
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00009763171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor