Provider Demographics
NPI:1104960855
Name:MARCOLONGO, ELLEN (ARNP)
Entity type:Individual
Prefix:DR
First Name:ELLEN
Middle Name:
Last Name:MARCOLONGO
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:148 115TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-2801
Mailing Address - Country:US
Mailing Address - Phone:727-577-3759
Mailing Address - Fax:
Practice Address - Street 1:5985 49TH ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33709-2111
Practice Address - Country:US
Practice Address - Phone:727-527-5060
Practice Address - Fax:727-230-9194
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2015-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9205990363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL15607001OtherCITRUS-49TH STREET
FL308213000Medicaid
FL308266OtherAVMED
FLP00662873OtherMEDICARE-RAILROAD
FL01130239OtherAMERIGROUP-MEDICARE
FL1062439OtherCAREPLUS
FL201266825OtherBEECH STREET
FLP03332OtherFREEDOM HEALTH
FL15607003OtherCITRUS-WEST BAY
FL15607002OtherCITRUS-PASADENA AVE S
FL3082130OtherMEDIPASS
FLY113DOtherBLUE CROSS BLUE SHEILD OF FLORIDA
FL201266825OtherMOLINA
FL308213000OtherMEDIPASS
FL1062439OtherCAREPLUS
FL201266825OtherMOLINA
FLU4827ZMedicare ID - Type Unspecified