1942302658 NPI number — SHIRLEY B ELLSWORTH NP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1942302658 NPI number — SHIRLEY B ELLSWORTH NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLSWORTH
Provider First Name:
SHIRLEY
Provider Middle Name:
B
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1942302658
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/16/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1055 N 500 W
Provider Second Line Business Mailing Address:
CREDENTIALING DEPARTMENT
Provider Business Mailing Address City Name:
PROVO
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84604-3305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-354-8215
Provider Business Mailing Address Fax Number:
801-429-8180

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1055 N 500 W
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
PROVO
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84604-3305
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
801-374-2367
Provider Business Practice Location Address Fax Number:
801-429-8015
Provider Enumeration Date:
09/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363L00000X , with the licence number:  2629084405 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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