Provider Demographics
NPI:1427689025
Name:DART, ELLEN J
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:J
Last Name:DART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 359
Mailing Address - Street 2:
Mailing Address - City:GLEN SPEY
Mailing Address - State:NY
Mailing Address - Zip Code:12737-0359
Mailing Address - Country:US
Mailing Address - Phone:845-856-3789
Mailing Address - Fax:
Practice Address - Street 1:961 COUNTY ROUTE 31
Practice Address - Street 2:
Practice Address - City:GLEN SPEY
Practice Address - State:NY
Practice Address - Zip Code:12737-5828
Practice Address - Country:US
Practice Address - Phone:845-856-3789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-01
Last Update Date:2020-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY4781121163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4781121OtherRN LIC NBR