Provider Demographics
NPI:1952378895
Name:ELLSWORTH, VIANN G (CNS)
Entity Type:Individual
Prefix:
First Name:VIANN
Middle Name:G
Last Name:ELLSWORTH
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:VIANN
Other - Middle Name:GRACE
Other - Last Name:MCINTIRE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:909 E STATE BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-3404
Mailing Address - Country:US
Mailing Address - Phone:260-481-2700
Mailing Address - Fax:260-481-2717
Practice Address - Street 1:909 E STATE BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-3404
Practice Address - Country:US
Practice Address - Phone:260-481-2700
Practice Address - Fax:260-481-2717
Is Sole Proprietor?:No
Enumeration Date:2006-02-28
Last Update Date:2015-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN70000031A364SP0812X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0812XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Community
Provider Identifiers
StateIdentifier IDID TypeIssuer
S66875Medicare UPIN
IN945300DDMedicare ID - Type Unspecified