Provider Demographics
NPI:1215343470
Name:AMATO, ELLYN REYNELL (NP)
Entity type:Individual
Prefix:
First Name:ELLYN
Middle Name:REYNELL
Last Name:AMATO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:ELLYN
Other - Middle Name:REYNELL
Other - Last Name:FARRAR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12100 WARWICK BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-2365
Practice Address - Country:US
Practice Address - Phone:757-534-5555
Practice Address - Fax:757-534-5567
Is Sole Proprietor?:No
Enumeration Date:2014-07-09
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024171792363LA2100X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology