1700198496 NPI number — IONA MARIE ELLSWORTH-JENSEN RNBS

Table of content: IONA MARIE ELLSWORTH-JENSEN RNBS (NPI 1700198496)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700198496 NPI number — IONA MARIE ELLSWORTH-JENSEN RNBS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLSWORTH-JENSEN
Provider First Name:
IONA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RNBS
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:
1700198496
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1337
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GALLUP
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
87305-1337
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
505-722-1000
Provider Business Mailing Address Fax Number:
505-722-1310

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
516 NIZHONI BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GALLUP
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
87301-5748
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
505-722-1000
Provider Business Practice Location Address Fax Number:
505-722-1310
Provider Enumeration Date:
07/09/2010

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: 163W00000X , with the licence number:  0001198594 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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