Provider Demographics
NPI:1093795585
Name:VAN FOSSEN, ELLEN T (RN, APN)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:T
Last Name:VAN FOSSEN
Suffix:
Gender:F
Credentials:RN, APN
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:T
Other - Last Name:DODDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:42 E LAUREL RD
Mailing Address - Street 2:UDP #1800
Mailing Address - City:STRATFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:08084-1354
Mailing Address - Country:US
Mailing Address - Phone:856-566-6843
Mailing Address - Fax:856-566-6419
Practice Address - Street 1:42 LAUREL RD E
Practice Address - Street 2:UDP #1800
Practice Address - City:STRATFORD
Practice Address - State:NJ
Practice Address - Zip Code:08084-1354
Practice Address - Country:US
Practice Address - Phone:856-566-6843
Practice Address - Fax:856-566-6419
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNO08244100163W00000X
NJNN08244100363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8132208Medicaid
NJS98663Medicare UPIN
035189CKPMedicare PIN