Provider Demographics
NPI:1528141504
Name:ELY, JILL VENTRELLA (APRN)
Entity type:Individual
Prefix:
First Name:JILL
Middle Name:VENTRELLA
Last Name:ELY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:292 LONG RIDGE RD STE 206
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-1627
Mailing Address - Country:US
Mailing Address - Phone:203-276-7213
Mailing Address - Fax:203-276-4975
Practice Address - Street 1:292 LONG RIDGE RD
Practice Address - Street 2:FAIRFIELD COUNTY DIABETES AND ENDOCRINE CENTER
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-1627
Practice Address - Country:US
Practice Address - Phone:203-276-7213
Practice Address - Fax:203-276-4975
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT02119363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTP30355Medicare UPIN