Provider Demographics
NPI:1528238540
Name:ELLSWORTH, DONALD DEAN (ARNP-BC)
Entity type:Individual
Prefix:MR
First Name:DONALD
Middle Name:DEAN
Last Name:ELLSWORTH
Suffix:
Gender:M
Credentials:ARNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 PRUDENTIAL DR
Mailing Address - Street 2:TOWER B, 11TH FLOOR
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8202
Mailing Address - Country:US
Mailing Address - Phone:904-388-6518
Mailing Address - Fax:904-384-1005
Practice Address - Street 1:800 PRUDENTIAL DR
Practice Address - Street 2:TOWER B, 11TH FLOOR
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8202
Practice Address - Country:US
Practice Address - Phone:904-388-6518
Practice Address - Fax:904-384-1005
Is Sole Proprietor?:No
Enumeration Date:2008-03-05
Last Update Date:2016-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2151382363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL309007800Medicaid
FLAL538ZMedicare PIN