1285300772 NPI number — MARY VIRGINIA ELLINGTON NURSE PRACTITIONER

Table of content: MARY VIRGINIA ELLINGTON NURSE PRACTITIONER (NPI 1285300772)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285300772 NPI number — MARY VIRGINIA ELLINGTON NURSE PRACTITIONER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLINGTON
Provider First Name:
MARY
Provider Middle Name:
VIRGINIA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NURSE PRACTITIONER
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:
1285300772
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/07/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1871 US HIGHWAY 41A S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DIXON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42409-9448
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-249-6037
Provider Business Mailing Address Fax Number:
270-440-0007

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1871 US41A SOUTH
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DIXON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42409
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-543-6372
Provider Business Practice Location Address Fax Number:
270-440-2109
Provider Enumeration Date:
08/17/2021

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: 363LF0000X , with the licence number:  3016526 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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