1760413827 NPI number — KIMBERLY D ELLSWORTH PT

Table of content: KIMBERLY D ELLSWORTH PT (NPI 1760413827)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760413827 NPI number — KIMBERLY D ELLSWORTH PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ELLSWORTH
Provider First Name:
KIMBERLY
Provider Middle Name:
D
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT
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:
1760413827
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 SHIRLEY CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILLISTON
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05495-7351
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-879-3545
Provider Business Mailing Address Fax Number:
802-878-9592

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1 MARKET PL
Provider Second Line Business Practice Location Address:
SUITE #27&33
Provider Business Practice Location Address City Name:
ESSEX JUNCTION
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05452-2942
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-878-9572
Provider Business Practice Location Address Fax Number:
802-878-9592
Provider Enumeration Date:
07/06/2006

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: 225100000X , with the licence number:  0400003140 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1008564 , issued by the state of ( VT ) . This identifiers is of the category "MEDICAID".




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